Comprehensive
Nursing Synthesis &
Clinical Judgment
Examination
2026/2027
,**Question
The nurse is caring for a client who is experiencing acute alcohol withdrawal. Which assessment finding
requires the nurse's immediate priority intervention?
A. Diaphoresis and tremors
B. Nausea and vomiting
C. Auditory hallucinations
D. Heart rate of 118 bpm
💫RATIONALE✔️✔️: While diaphoresis, tremors, nausea, vomiting, and hallucinations are all signs of
alcohol withdrawal, a heart rate of 118 bpm indicates significant autonomic hyperactivity, which can
quickly progress to life-threatening cardiovascular instability or seizures. This finding requires immediate
intervention to prevent further deterioration.
💫ANSWER✔️✔️: D. Heart rate of 118 bpm
---
**Question 2**
A nurse is preparing to administer an enteral feeding through a nasogastric (NG) tube. Which action is
most important to perform prior to the feeding?
A. Flush the tube with 30 mL of warm water.
B. Verify the placement of the tube by assessing the pH of aspirated fluid.
C. Place the client in a supine position.
,D. Check the residual volume to confirm absorption.
💫RATIONALE✔️✔️: The most critical action is to verify the tube's placement to prevent accidental
instillation of feeding into the lungs. While pH testing is one method to confirm placement, the most
reliable method is an X-ray. Auscultation and observing aspirate are less reliable. The client should be in
a semi-Fowler's or high-Fowler's position to prevent aspiration, not supine. Checking residuals and
flushing are also important but secondary to verifying safe placement.
💫ANSWER✔️✔️: B. Verify the placement of the tube by assessing the pH of aspirated fluid. (Note: A
chest X-ray is the gold standard, but among the options, verifying placement is the primary safety
action.)
---
**Question 3**
A postpartum client who is 24 hours post-delivery reports a sudden onset of sharp chest pain and
shortness of breath. Which action should the nurse take first?
A. Administer a PRN dose of morphine sulfate.
B. Assess the client's vital signs and oxygen saturation.
C. Instruct the client to cough and deep breathe.
D. Ask the client about a history of pulmonary embolism.
💫RATIONALE✔️✔️: The nurse's first action is to assess the client's current physiological status by
obtaining vital signs and oxygen saturation. This provides objective data to determine the severity of the
situation and guides further interventions. While the client is at risk for a pulmonary embolism, the
priority is to assess before administering medications or assuming a diagnosis.
, 💫ANSWER✔️✔️: B. Assess the client's vital signs and oxygen saturation.
---
**Question 4**
The nurse is evaluating the effectiveness of a patient's incentive spirometer use. Which outcome
indicates proper performance and achievement of the goal?
A. The patient is able to cough effectively after the procedure.
B. The patient reports feeling less anxious.
C. The patient demonstrates sustained maximal inspiration by raising the indicator to the goal level.
D. The patient's respiratory rate has decreased to 14 breaths per minute.
💫RATIONALE✔️✔️: The purpose of an incentive spirometer is to promote sustained maximal
inspiration to prevent or treat atelectasis. Proper performance is objectively demonstrated when the
patient can raise the indicator to the prescribed goal level and hold it, indicating adequate lung
expansion. Coughing is a complementary but separate action.
💫ANSWER✔️✔️: C. The patient demonstrates sustained maximal inspiration by raising the indicator
to the goal level.
---
**Question 5**
A client with major depressive disorder is prescribed a monoamine oxidase inhibitor (MAOI). Which
dietary instruction is most important for the nurse to provide?
Nursing Synthesis &
Clinical Judgment
Examination
2026/2027
,**Question
The nurse is caring for a client who is experiencing acute alcohol withdrawal. Which assessment finding
requires the nurse's immediate priority intervention?
A. Diaphoresis and tremors
B. Nausea and vomiting
C. Auditory hallucinations
D. Heart rate of 118 bpm
💫RATIONALE✔️✔️: While diaphoresis, tremors, nausea, vomiting, and hallucinations are all signs of
alcohol withdrawal, a heart rate of 118 bpm indicates significant autonomic hyperactivity, which can
quickly progress to life-threatening cardiovascular instability or seizures. This finding requires immediate
intervention to prevent further deterioration.
💫ANSWER✔️✔️: D. Heart rate of 118 bpm
---
**Question 2**
A nurse is preparing to administer an enteral feeding through a nasogastric (NG) tube. Which action is
most important to perform prior to the feeding?
A. Flush the tube with 30 mL of warm water.
B. Verify the placement of the tube by assessing the pH of aspirated fluid.
C. Place the client in a supine position.
,D. Check the residual volume to confirm absorption.
💫RATIONALE✔️✔️: The most critical action is to verify the tube's placement to prevent accidental
instillation of feeding into the lungs. While pH testing is one method to confirm placement, the most
reliable method is an X-ray. Auscultation and observing aspirate are less reliable. The client should be in
a semi-Fowler's or high-Fowler's position to prevent aspiration, not supine. Checking residuals and
flushing are also important but secondary to verifying safe placement.
💫ANSWER✔️✔️: B. Verify the placement of the tube by assessing the pH of aspirated fluid. (Note: A
chest X-ray is the gold standard, but among the options, verifying placement is the primary safety
action.)
---
**Question 3**
A postpartum client who is 24 hours post-delivery reports a sudden onset of sharp chest pain and
shortness of breath. Which action should the nurse take first?
A. Administer a PRN dose of morphine sulfate.
B. Assess the client's vital signs and oxygen saturation.
C. Instruct the client to cough and deep breathe.
D. Ask the client about a history of pulmonary embolism.
💫RATIONALE✔️✔️: The nurse's first action is to assess the client's current physiological status by
obtaining vital signs and oxygen saturation. This provides objective data to determine the severity of the
situation and guides further interventions. While the client is at risk for a pulmonary embolism, the
priority is to assess before administering medications or assuming a diagnosis.
, 💫ANSWER✔️✔️: B. Assess the client's vital signs and oxygen saturation.
---
**Question 4**
The nurse is evaluating the effectiveness of a patient's incentive spirometer use. Which outcome
indicates proper performance and achievement of the goal?
A. The patient is able to cough effectively after the procedure.
B. The patient reports feeling less anxious.
C. The patient demonstrates sustained maximal inspiration by raising the indicator to the goal level.
D. The patient's respiratory rate has decreased to 14 breaths per minute.
💫RATIONALE✔️✔️: The purpose of an incentive spirometer is to promote sustained maximal
inspiration to prevent or treat atelectasis. Proper performance is objectively demonstrated when the
patient can raise the indicator to the prescribed goal level and hold it, indicating adequate lung
expansion. Coughing is a complementary but separate action.
💫ANSWER✔️✔️: C. The patient demonstrates sustained maximal inspiration by raising the indicator
to the goal level.
---
**Question 5**
A client with major depressive disorder is prescribed a monoamine oxidase inhibitor (MAOI). Which
dietary instruction is most important for the nurse to provide?
