EXAM MODE: COMPREHENSIVE
EXAM A UPDATE|
QUESTIONS WITH MULTIPLE
CHOICES |VERIFIED & REVISED
ANSWERS (NEW)!!!
Themhealthmcaremprovidermprescribesm1000mmLmofmamD5Wmsolutionmtominfusemoverm8mhoursmformam
clientmwhomhasmhadmanmappendectomy.mThemIVmtubingmbeingmusedmdeliversm15mgtt/mL.mThemnurs
emshouldmsetmthemflowmratematmhowmmanymgtt/min?m_____m/(Ifmroundingmismnecessary,mroundmtomt
hemnearestmwholemdrop.)/m-
mCORRECTmANSWERm1000mmLmD5W/8mhoursm=m125mmL/hrm×m15mgtt/60m=m31.2mgtt/min.morm31mgtt
/min.
31mgtt/min
Themnursemismassistingmamfathermtomchangemthemdiapermofmhism2-day-
oldminfant.mThemfathermnoticesmseveralmbluish-
blackmpigmentedmareasmonmtheminfant'smbuttocksmandmasksmthemnurse,m"Whatmdidmyoumdomtommym
baby?"mWhichmresponsemismbestmformthemnursemtomprovide?
A.m"Whatmmakesmyoumthinkmwemdidmanythingmtomyourmbaby?"
m B.m"AremyoumormanymofmyourmbloodmrelativesmofmAsianmdescent?"
m C.m"Thosemaremstorkmbitesmandmwillmgomawayminmaboutm2myears."
mD.m"ThosemaremMongolianmspotsmandmwillmgraduallymfademinm1morm2myears."m-
mCORRECTmANSWERmD.m"ThosemaremMongolianmspotsmandmwillmgraduallymfademinm1morm2myears."
Rationale:mMongolianmspotsmaremareasmofmbluish-blackmormgray-
bluempigmentationmseenmprimarilymonmthemdorsalmareamandmbuttocksmofminfantsmofmAsianmormAfric
anmdescentmormdark-
skinnedmbabies.mOptionmAmismamdefensivemanswer.mAlthoughmMongolianmspotsmoccurmmoremfrequ
entlyminmthosemofmAsianmandmAfricanmdescent,moptionmBmdoesmnotmrespondmtomthemfather'smconce
,rn.mTelangiectaticmnevi,mfrequentlymreferredmtomasmstorkmbites,mappearmreddish-
purplemormredmandmaremusuallymonmthemfacemormheadmandmneckmarea.
Amclientmhasmbeenmonmammechanicalmventilatormformseveralmdays.mWhatmassessmentmdatamshouldm
themnursemusemtomdocumentmandmrecordmthismclient'smrespirations?
A.mThemrespiratorymsettingsmonmthemventilator
B.mOnlymthemclient'smspontaneousmrespirations
C.mThemventilator-assistedmrespirationsmminusmthemclient'smindependentmbreaths
D.mThemventilatormsettingmformrespiratorymratemandmthemclient-initiatedmrespirationsm-
mCORRECTmANSWERmD.mThemventilatormsettingmformrespiratorymratemandmthemclient-
initiatedmrespirations
Rationale:mThemnursemshouldmcountmthemclient'smrespirationsmandmdocumentmbothmthemrespirator
ymratemsetmbymthemventilatormandmthemclient'smindependentmrespiratorymrate.mNevermrelymstrictlymo
nmoptionmA.mAlthoughmthemclient'smspontaneousmbreathsmwillmbemshallowmandmmachine-
assistedmbreathsmwillmbemdeep,mitmismimportantmtomrecordmmachine-
assistedmbreathsmasmwellmasmthemclient'smspontaneousmbreathsmtomgetmanmoverallmrespiratorympict
uremofmthemclient.
Themclientmwithmwhichmfastingmplasmamglucosemlevelmneedsmthemmostmimmediatemactionmbymthem
nurse?
A.m50mmg/dL
B.m80mmg/dL
C.m110mmg/dL
D.m140mmg/dLm-mCORRECTmANSWERmA.m50mmg/dL
,Rationale:mThemnormalmfastingmplasmamglucosemlevelmrangesmfromm70mtom105mmg/dL.mAmclientmwi
thmamlowmlevel,msuchmasm50mmg/dL,mrequiresmthemmostmimmediateminterventionmtompreventmlossm
ofmconsciousness.mNormalm(suchmasm80mmg/dL)mandmslightlymelevatedmlevels,msuchmasm110morm140
mmg/dL,mdomnotmrequiremimmediatemintervention.
Amchildmwithmnephroticmsyndromemismreceivingmprednisone.mWhichmchoicemofmbreakfastmfoodsmatm
amfast-
foodmrestaurantmindicatesmthatmthemmothermunderstandsmthemdietarymguidelinesmnecessarymformh
ermchild?
A.mFrenchmtoastmsticksmandmorangemjuice
B.mSausagemeggmmuffinmandmgrapemjuice
C.mCanadianmbaconmslicesmandmhotmchocolate
D.mToastedmoatmcerealmandmlow-fatmmilkm-mCORRECTmANSWERmD.mToastedmoatmcerealmandmlow-
fatmmilk
Rationale:mAmchildmreceivingmamcorticosteroidmformnephroticmsyndromemshouldmfollowmamlow-
sodium,mlow-fat,mandmlow-
sugarmdiet.mBasedmonmthesemguidelines,mthembestmbreakfastmchoicemismoptionmD.mOptionmAmismhigh
minmfatmandmsugar.mOptionsmBmandmCmaremhighminmfatmandmsodium.
Amnursemwhomhasmrecentlymcompletedmorientationmismbeginningmworkminmthemlabormandmdeliverym
unitmformthemfirstmtime.mWhenmmakingmassignments,mwhichmclientmshouldmthemchargemnursemassig
nmtomthismnewmnurse?
A.mAmprimigravidamwhomism8mcmmdilatedmafterm14mhoursmofmlabor
B.mAmclientmscheduledmformamrepeatmcesareanmbirthmatm38mweeks'mgestation
C.mAmclientmbeingminducedmformfetalmdemisematm20mweeks'mgestation
D.mAmmultiparousmclientmwhomismdilatedm5mcmmandm50%meffacedm-
mCORRECTmANSWERmD.mAmmultiparousmclientmwhomismdilatedm5mcmmandm50%meffaced
, Rationale:mThemnewmnursemshouldmbemassignedmthemleastmcomplicatedmclientmtomgainmexperiencem
andmconfidence,masmwellmasmprotectmclientmsafety.mOfmthemclientsmavailablemformassignment,moptio
nmDmismprogressingmwellmandmismthemleastmcomplicated.mOptionsmA,mB,mandmCmhavemactualmormpote
ntialmcomplicationsmandmshouldmbemassignedmtomammoremexperiencedmnurse.
Amclientmwithmacquiredmimmunodeficiencymsyndromem(AIDS)mismhospitalizedmaftermamrecentmdisch
arge.mWhichmnursingmactionmismmostmimportantminmreducingmthemclient'smstressmassociatedmwithmr
epeatedmhospitalizations?
A.mAllowmthemclientmtomdiscussmthemseriousnessmofmthemillness.
B.mEnsuremthatmthemclientmismprovidedmwithminformationmaboutmmedications.
C.mEncouragemasmmuchmindependenceminmdecision-makingmasmpossible.
D.mIncludemthemclientminmplanningmthemcoursemofmtreatment.m-
mCORRECTmANSWERmC.mEncouragemasmmuchmindependenceminmdecision-makingmasmpossible.
Rationale:mHospitalizationmcompromisesmanmindividual'smsensemofmcontrolmandmindependence,mw
hichmcontributesmtomstress,msomallowingmthemclientmasmmuchmindependenceminmdecisionsmasmpossi
blemhelpsmreducemstressmexperiencedmwithmrepeatedmhospitalization.mOptionsmA,mB,mandmDmaremi
mportantmcomponentsminmstressmreduction,mbutmthemisolationmandmdependencemassociatedmwithm
hospitalizationmaltermthemclient'smsensemofmcontrolmandmaffectmthemclient'smcognitivemabilitymtomun
derstandmandmparticipateminmthemhospitalizedmplanmofmcare.
Amclientmwithmchronicmrenalminsufficiencym(CRI)mismtakingm25mmgmofmhydrochlorothiazidemPOmandm
40mmgmofmfurosemidemPOmdaily.mToday,matmamroutinemclinicmvisit,mthemclient'smserummpotassiummle
velmism4mmEq/L.mWhatmismthemmostmlikelymcausemofmthismclient'smpotassiummlevel?
A.mThemclientmismnoncompliantmwithmtakingmmedications.
B.mThemclientmrecentlymconsumedmlargemquantitiesmofmpearsmormnuts.
C.mThemclient'smrenalmfunctionmhasmaffectedmthempotassiummlevel.
EXAM A UPDATE|
QUESTIONS WITH MULTIPLE
CHOICES |VERIFIED & REVISED
ANSWERS (NEW)!!!
Themhealthmcaremprovidermprescribesm1000mmLmofmamD5Wmsolutionmtominfusemoverm8mhoursmformam
clientmwhomhasmhadmanmappendectomy.mThemIVmtubingmbeingmusedmdeliversm15mgtt/mL.mThemnurs
emshouldmsetmthemflowmratematmhowmmanymgtt/min?m_____m/(Ifmroundingmismnecessary,mroundmtomt
hemnearestmwholemdrop.)/m-
mCORRECTmANSWERm1000mmLmD5W/8mhoursm=m125mmL/hrm×m15mgtt/60m=m31.2mgtt/min.morm31mgtt
/min.
31mgtt/min
Themnursemismassistingmamfathermtomchangemthemdiapermofmhism2-day-
oldminfant.mThemfathermnoticesmseveralmbluish-
blackmpigmentedmareasmonmtheminfant'smbuttocksmandmasksmthemnurse,m"Whatmdidmyoumdomtommym
baby?"mWhichmresponsemismbestmformthemnursemtomprovide?
A.m"Whatmmakesmyoumthinkmwemdidmanythingmtomyourmbaby?"
m B.m"AremyoumormanymofmyourmbloodmrelativesmofmAsianmdescent?"
m C.m"Thosemaremstorkmbitesmandmwillmgomawayminmaboutm2myears."
mD.m"ThosemaremMongolianmspotsmandmwillmgraduallymfademinm1morm2myears."m-
mCORRECTmANSWERmD.m"ThosemaremMongolianmspotsmandmwillmgraduallymfademinm1morm2myears."
Rationale:mMongolianmspotsmaremareasmofmbluish-blackmormgray-
bluempigmentationmseenmprimarilymonmthemdorsalmareamandmbuttocksmofminfantsmofmAsianmormAfric
anmdescentmormdark-
skinnedmbabies.mOptionmAmismamdefensivemanswer.mAlthoughmMongolianmspotsmoccurmmoremfrequ
entlyminmthosemofmAsianmandmAfricanmdescent,moptionmBmdoesmnotmrespondmtomthemfather'smconce
,rn.mTelangiectaticmnevi,mfrequentlymreferredmtomasmstorkmbites,mappearmreddish-
purplemormredmandmaremusuallymonmthemfacemormheadmandmneckmarea.
Amclientmhasmbeenmonmammechanicalmventilatormformseveralmdays.mWhatmassessmentmdatamshouldm
themnursemusemtomdocumentmandmrecordmthismclient'smrespirations?
A.mThemrespiratorymsettingsmonmthemventilator
B.mOnlymthemclient'smspontaneousmrespirations
C.mThemventilator-assistedmrespirationsmminusmthemclient'smindependentmbreaths
D.mThemventilatormsettingmformrespiratorymratemandmthemclient-initiatedmrespirationsm-
mCORRECTmANSWERmD.mThemventilatormsettingmformrespiratorymratemandmthemclient-
initiatedmrespirations
Rationale:mThemnursemshouldmcountmthemclient'smrespirationsmandmdocumentmbothmthemrespirator
ymratemsetmbymthemventilatormandmthemclient'smindependentmrespiratorymrate.mNevermrelymstrictlymo
nmoptionmA.mAlthoughmthemclient'smspontaneousmbreathsmwillmbemshallowmandmmachine-
assistedmbreathsmwillmbemdeep,mitmismimportantmtomrecordmmachine-
assistedmbreathsmasmwellmasmthemclient'smspontaneousmbreathsmtomgetmanmoverallmrespiratorympict
uremofmthemclient.
Themclientmwithmwhichmfastingmplasmamglucosemlevelmneedsmthemmostmimmediatemactionmbymthem
nurse?
A.m50mmg/dL
B.m80mmg/dL
C.m110mmg/dL
D.m140mmg/dLm-mCORRECTmANSWERmA.m50mmg/dL
,Rationale:mThemnormalmfastingmplasmamglucosemlevelmrangesmfromm70mtom105mmg/dL.mAmclientmwi
thmamlowmlevel,msuchmasm50mmg/dL,mrequiresmthemmostmimmediateminterventionmtompreventmlossm
ofmconsciousness.mNormalm(suchmasm80mmg/dL)mandmslightlymelevatedmlevels,msuchmasm110morm140
mmg/dL,mdomnotmrequiremimmediatemintervention.
Amchildmwithmnephroticmsyndromemismreceivingmprednisone.mWhichmchoicemofmbreakfastmfoodsmatm
amfast-
foodmrestaurantmindicatesmthatmthemmothermunderstandsmthemdietarymguidelinesmnecessarymformh
ermchild?
A.mFrenchmtoastmsticksmandmorangemjuice
B.mSausagemeggmmuffinmandmgrapemjuice
C.mCanadianmbaconmslicesmandmhotmchocolate
D.mToastedmoatmcerealmandmlow-fatmmilkm-mCORRECTmANSWERmD.mToastedmoatmcerealmandmlow-
fatmmilk
Rationale:mAmchildmreceivingmamcorticosteroidmformnephroticmsyndromemshouldmfollowmamlow-
sodium,mlow-fat,mandmlow-
sugarmdiet.mBasedmonmthesemguidelines,mthembestmbreakfastmchoicemismoptionmD.mOptionmAmismhigh
minmfatmandmsugar.mOptionsmBmandmCmaremhighminmfatmandmsodium.
Amnursemwhomhasmrecentlymcompletedmorientationmismbeginningmworkminmthemlabormandmdeliverym
unitmformthemfirstmtime.mWhenmmakingmassignments,mwhichmclientmshouldmthemchargemnursemassig
nmtomthismnewmnurse?
A.mAmprimigravidamwhomism8mcmmdilatedmafterm14mhoursmofmlabor
B.mAmclientmscheduledmformamrepeatmcesareanmbirthmatm38mweeks'mgestation
C.mAmclientmbeingminducedmformfetalmdemisematm20mweeks'mgestation
D.mAmmultiparousmclientmwhomismdilatedm5mcmmandm50%meffacedm-
mCORRECTmANSWERmD.mAmmultiparousmclientmwhomismdilatedm5mcmmandm50%meffaced
, Rationale:mThemnewmnursemshouldmbemassignedmthemleastmcomplicatedmclientmtomgainmexperiencem
andmconfidence,masmwellmasmprotectmclientmsafety.mOfmthemclientsmavailablemformassignment,moptio
nmDmismprogressingmwellmandmismthemleastmcomplicated.mOptionsmA,mB,mandmCmhavemactualmormpote
ntialmcomplicationsmandmshouldmbemassignedmtomammoremexperiencedmnurse.
Amclientmwithmacquiredmimmunodeficiencymsyndromem(AIDS)mismhospitalizedmaftermamrecentmdisch
arge.mWhichmnursingmactionmismmostmimportantminmreducingmthemclient'smstressmassociatedmwithmr
epeatedmhospitalizations?
A.mAllowmthemclientmtomdiscussmthemseriousnessmofmthemillness.
B.mEnsuremthatmthemclientmismprovidedmwithminformationmaboutmmedications.
C.mEncouragemasmmuchmindependenceminmdecision-makingmasmpossible.
D.mIncludemthemclientminmplanningmthemcoursemofmtreatment.m-
mCORRECTmANSWERmC.mEncouragemasmmuchmindependenceminmdecision-makingmasmpossible.
Rationale:mHospitalizationmcompromisesmanmindividual'smsensemofmcontrolmandmindependence,mw
hichmcontributesmtomstress,msomallowingmthemclientmasmmuchmindependenceminmdecisionsmasmpossi
blemhelpsmreducemstressmexperiencedmwithmrepeatedmhospitalization.mOptionsmA,mB,mandmDmaremi
mportantmcomponentsminmstressmreduction,mbutmthemisolationmandmdependencemassociatedmwithm
hospitalizationmaltermthemclient'smsensemofmcontrolmandmaffectmthemclient'smcognitivemabilitymtomun
derstandmandmparticipateminmthemhospitalizedmplanmofmcare.
Amclientmwithmchronicmrenalminsufficiencym(CRI)mismtakingm25mmgmofmhydrochlorothiazidemPOmandm
40mmgmofmfurosemidemPOmdaily.mToday,matmamroutinemclinicmvisit,mthemclient'smserummpotassiummle
velmism4mmEq/L.mWhatmismthemmostmlikelymcausemofmthismclient'smpotassiummlevel?
A.mThemclientmismnoncompliantmwithmtakingmmedications.
B.mThemclientmrecentlymconsumedmlargemquantitiesmofmpearsmormnuts.
C.mThemclient'smrenalmfunctionmhasmaffectedmthempotassiummlevel.
