NSG 48001 COMPREHENSIVE EXAM 2
Updated for 2026
1. The nurse is preparing to administer prescribed medications to the following clients. It is most
important for the nurse to follow up with the PCP for the client who has:
a. A prosthetic mitral valve, an INR of 3.0 and is currently taking a prescribed dose of warfarin
b. Constipation predominant IBS and has been prescribed loperamide
c. Diabetes mellitus, is scheduled to have a computer tomography scan with IV contrast, and has been
prescribed to withhold metformin
d. A methicillin-resistant staphylococcus aureus wound infection, an allergy to sulfonamide, and has
been prescribed vancomycin
ANSWER: B
Rationale:
Option A: An INR of 3.0 is within the therapeutic range (2.0-3.5) for a client with a prosthetic mitral valve
taking warfarin. This is an expected finding and does not require follow-up.
Option B: Loperamide is contraindicated in constipation-predominant IBS as it slows intestinal motility
and would worsen constipation. This requires immediate follow-up with the PCP to clarify the
prescription.
Option C: Withholding metformin before a CT scan with IV contrast is the correct intervention to
prevent contrast-induced nephropathy and potential lactic acidosis. This is appropriate care.
Option D: Vancomycin is the appropriate antibiotic for MRSA infections, and the client's sulfonamide
allergy does not cross-react with vancomycin. This is safe administration.
2. The nurse is preparing to administer an intramuscular injection to an adult client. Which of the
following actions is appropriate for the nurse to take?
a. Limit the amount of medication to 4ml when injecting into the deltoid muscle
b. Use the deltoid site if the client is an adult who requires 3ml of medication
c. Draw up an air bubble into the syringe after the medications has been prepared
d. Hold the skin taut when using the z-track method
,ANSWER: D
Rationale:
Option A: The deltoid muscle can safely accommodate only 1-2 ml of medication in adults, not 4 ml.
Larger volumes should be administered in the ventrogluteal or vastus lateralis muscles.
Option B: The deltoid site is appropriate for volumes of 1-2 ml only. A 3 ml volume requires a larger
muscle such as the ventrogluteal or vastus lateralis.
Option C: Air bubbles are not routinely drawn up for IM injections in modern practice. The z-track
technique may use a small air lock (0.2-0.5 ml) but this is added after the medication, not drawn up
separately.
Option D: Holding the skin taut is the correct technique for z-track IM injections. This displaces the skin
and subcutaneous tissue to prevent medication tracking and ensures proper deposition in the muscle.
3. The nurse is discussing health screening guidelines with a group of men. It is appropriate for the nurse
to state that men should:
a. Perform a monthly testicular self-examination immediately after a bath or shower
b. Begin having a sigmoidoscopy once every 10 years beginning at age 50 (every 5 years once year are
45)
c. Begin having an annual prostate examination beginning at age 40 (50 years old every 2 years)
d. Be tested annually for sexually transmitted diseases upon becoming sexually active
ANSWER: A
Rationale:
Option A: Monthly testicular self-examination should be performed after a warm bath or shower when
the scrotal skin is relaxed, making examination easier and more effective. This is the correct teaching.
Option B: Current guidelines recommend colorectal cancer screening beginning at age 45, not 50.
Sigmoidoscopy is recommended every 5 years, not every 10 years.
Option C: Prostate examination guidelines vary, but routine annual screening is not universally
recommended. Shared decision-making is recommended for men aged 55-69 years.
Option D: STD testing frequency depends on risk factors, sexual practices, and specific infections. Annual
testing is not necessary for all sexually active men unless they have specific risk factors.
4. The nurse manager is observing a staff nurse care for a client who has a sealed radiation implant.
Which of the following would require the nurse to intervene?
a. Keeping the door to the client's room closed
b. Keeping dedicated equipment in the clients until the implant is removed
c. Wearing a lead shield when providing client care
,d. Placing bed linens in a receptacle kept inside the client's room
ANSWER: D
Rationale:
Option A: Keeping the door closed is appropriate for radiation safety to minimize exposure to others.
This is correct practice.
Option B: Dedicated equipment should remain in the room until the radiation implant is removed to
prevent contamination of other areas. This is appropriate.
Option C: Wearing lead shielding protects healthcare workers from radiation exposure during client
care. This is correct safety practice.
Option D: Bed linens from a client with a radiation implant should be kept in the room initially but must
be monitored with a radiation detection device before being removed. Simply placing them in a
receptacle inside the room without proper monitoring protocols requires intervention.
5. The nurse is reviewing prescriptions for the following assigned clients. The nurse should clarify the
prescription for the client who:
a. Presented with clinical manifestations of an ischemic stroke that started 2 hours ago and is to receive
alteplase intravenously
b. Has creatinine level of 2.8 mg/dl and is scheduled to have a cardiac catheterization in the morning
c. Had a myocardial infarction 3 hours ago and is to have troponin levels drawn in 3 hours
d. Had a permanent pacemaker inserted 6 months ago and is scheduled for a radiography (x-ray) of the
chest
ANSWER: B
Rationale:
Option A: Alteplase (tPA) is indicated for ischemic stroke within 3-4.5 hours of symptom onset.
Administration at 2 hours is appropriate and within the therapeutic window.
Option B: A creatinine level of 2.8 mg/dl indicates significant renal impairment. IV contrast used in
cardiac catheterization can cause further kidney damage. The prescription requires clarification
regarding renal protection protocols or alternative imaging.
Option C: Serial troponin levels are standard after MI to monitor cardiac damage. Drawing troponin 3
hours after the initial draw is appropriate for trend monitoring.
Option D: Chest x-ray is safe for clients with permanent pacemakers and does not interfere with
pacemaker function. This is appropriate.
6. The nurse preceptor has discussed appropriate dietary intake for various ages of pediatric clients with
a newly hired nurse. Which of the following statements by the newly hired nurse indicated a need for
further teaching?
, a. Sliced banana is an appropriate snack for a toddler-aged child
b. Milk is introduced as 12 months of age in an infant which has been breastfed since birth
c. Honey can be introduced to an infant at 9 months of age (needs to be 1 year)
d. 4oz fruit juice can be given in a cup to a 13-month-old infant per...
ANSWER: C
Rationale:
Option A: Sliced bananas are soft, easy to chew, and appropriate for toddlers. This demonstrates correct
knowledge.
Option B: Whole cow's milk can be introduced at 12 months of age in breastfed infants. This is correct.
Option C: Honey should NOT be given to infants before 12 months of age due to the risk of infant
botulism. The statement that honey can be given at 9 months indicates a knowledge deficit requiring
further teaching.
Option D: Small amounts (4 oz) of fruit juice in a cup are appropriate after 12 months of age. This shows
correct understanding.
7. The nurse is assessing a client at the scene of a mass casualty disaster and prioritizing care based on
the disaster triage tag system. The client who should be transported to the healthcare facility first is the
one:
a. Patient who is confused and has an open wound on the right lower leg
b. Patient who has multiple compound fracture and is reporting chest pain
c. Patient who reports an abdominal pain and has facial lacerations
d. Patient who has burns to 75% of the posterior trunk and lower body
ANSWER: B
Rationale:
Option A: Confusion with an open lower leg wound would likely be tagged yellow (delayed). The wound
is not immediately life-threatening.
Option B: Multiple compound fractures with chest pain suggests potential internal injuries and
compromised circulation/respiration. This client would be tagged red (immediate) and transported first
as they have life-threatening injuries that are treatable.
Option C: Abdominal pain and facial lacerations without other specified symptoms would likely be
tagged yellow (delayed) as these are not immediately life-threatening.
Option D: Burns to 75% of body surface area, especially in a mass casualty situation, would likely be
tagged black (expectant) as survival is unlikely despite treatment, and resources should be directed to
those with better prognosis.
Updated for 2026
1. The nurse is preparing to administer prescribed medications to the following clients. It is most
important for the nurse to follow up with the PCP for the client who has:
a. A prosthetic mitral valve, an INR of 3.0 and is currently taking a prescribed dose of warfarin
b. Constipation predominant IBS and has been prescribed loperamide
c. Diabetes mellitus, is scheduled to have a computer tomography scan with IV contrast, and has been
prescribed to withhold metformin
d. A methicillin-resistant staphylococcus aureus wound infection, an allergy to sulfonamide, and has
been prescribed vancomycin
ANSWER: B
Rationale:
Option A: An INR of 3.0 is within the therapeutic range (2.0-3.5) for a client with a prosthetic mitral valve
taking warfarin. This is an expected finding and does not require follow-up.
Option B: Loperamide is contraindicated in constipation-predominant IBS as it slows intestinal motility
and would worsen constipation. This requires immediate follow-up with the PCP to clarify the
prescription.
Option C: Withholding metformin before a CT scan with IV contrast is the correct intervention to
prevent contrast-induced nephropathy and potential lactic acidosis. This is appropriate care.
Option D: Vancomycin is the appropriate antibiotic for MRSA infections, and the client's sulfonamide
allergy does not cross-react with vancomycin. This is safe administration.
2. The nurse is preparing to administer an intramuscular injection to an adult client. Which of the
following actions is appropriate for the nurse to take?
a. Limit the amount of medication to 4ml when injecting into the deltoid muscle
b. Use the deltoid site if the client is an adult who requires 3ml of medication
c. Draw up an air bubble into the syringe after the medications has been prepared
d. Hold the skin taut when using the z-track method
,ANSWER: D
Rationale:
Option A: The deltoid muscle can safely accommodate only 1-2 ml of medication in adults, not 4 ml.
Larger volumes should be administered in the ventrogluteal or vastus lateralis muscles.
Option B: The deltoid site is appropriate for volumes of 1-2 ml only. A 3 ml volume requires a larger
muscle such as the ventrogluteal or vastus lateralis.
Option C: Air bubbles are not routinely drawn up for IM injections in modern practice. The z-track
technique may use a small air lock (0.2-0.5 ml) but this is added after the medication, not drawn up
separately.
Option D: Holding the skin taut is the correct technique for z-track IM injections. This displaces the skin
and subcutaneous tissue to prevent medication tracking and ensures proper deposition in the muscle.
3. The nurse is discussing health screening guidelines with a group of men. It is appropriate for the nurse
to state that men should:
a. Perform a monthly testicular self-examination immediately after a bath or shower
b. Begin having a sigmoidoscopy once every 10 years beginning at age 50 (every 5 years once year are
45)
c. Begin having an annual prostate examination beginning at age 40 (50 years old every 2 years)
d. Be tested annually for sexually transmitted diseases upon becoming sexually active
ANSWER: A
Rationale:
Option A: Monthly testicular self-examination should be performed after a warm bath or shower when
the scrotal skin is relaxed, making examination easier and more effective. This is the correct teaching.
Option B: Current guidelines recommend colorectal cancer screening beginning at age 45, not 50.
Sigmoidoscopy is recommended every 5 years, not every 10 years.
Option C: Prostate examination guidelines vary, but routine annual screening is not universally
recommended. Shared decision-making is recommended for men aged 55-69 years.
Option D: STD testing frequency depends on risk factors, sexual practices, and specific infections. Annual
testing is not necessary for all sexually active men unless they have specific risk factors.
4. The nurse manager is observing a staff nurse care for a client who has a sealed radiation implant.
Which of the following would require the nurse to intervene?
a. Keeping the door to the client's room closed
b. Keeping dedicated equipment in the clients until the implant is removed
c. Wearing a lead shield when providing client care
,d. Placing bed linens in a receptacle kept inside the client's room
ANSWER: D
Rationale:
Option A: Keeping the door closed is appropriate for radiation safety to minimize exposure to others.
This is correct practice.
Option B: Dedicated equipment should remain in the room until the radiation implant is removed to
prevent contamination of other areas. This is appropriate.
Option C: Wearing lead shielding protects healthcare workers from radiation exposure during client
care. This is correct safety practice.
Option D: Bed linens from a client with a radiation implant should be kept in the room initially but must
be monitored with a radiation detection device before being removed. Simply placing them in a
receptacle inside the room without proper monitoring protocols requires intervention.
5. The nurse is reviewing prescriptions for the following assigned clients. The nurse should clarify the
prescription for the client who:
a. Presented with clinical manifestations of an ischemic stroke that started 2 hours ago and is to receive
alteplase intravenously
b. Has creatinine level of 2.8 mg/dl and is scheduled to have a cardiac catheterization in the morning
c. Had a myocardial infarction 3 hours ago and is to have troponin levels drawn in 3 hours
d. Had a permanent pacemaker inserted 6 months ago and is scheduled for a radiography (x-ray) of the
chest
ANSWER: B
Rationale:
Option A: Alteplase (tPA) is indicated for ischemic stroke within 3-4.5 hours of symptom onset.
Administration at 2 hours is appropriate and within the therapeutic window.
Option B: A creatinine level of 2.8 mg/dl indicates significant renal impairment. IV contrast used in
cardiac catheterization can cause further kidney damage. The prescription requires clarification
regarding renal protection protocols or alternative imaging.
Option C: Serial troponin levels are standard after MI to monitor cardiac damage. Drawing troponin 3
hours after the initial draw is appropriate for trend monitoring.
Option D: Chest x-ray is safe for clients with permanent pacemakers and does not interfere with
pacemaker function. This is appropriate.
6. The nurse preceptor has discussed appropriate dietary intake for various ages of pediatric clients with
a newly hired nurse. Which of the following statements by the newly hired nurse indicated a need for
further teaching?
, a. Sliced banana is an appropriate snack for a toddler-aged child
b. Milk is introduced as 12 months of age in an infant which has been breastfed since birth
c. Honey can be introduced to an infant at 9 months of age (needs to be 1 year)
d. 4oz fruit juice can be given in a cup to a 13-month-old infant per...
ANSWER: C
Rationale:
Option A: Sliced bananas are soft, easy to chew, and appropriate for toddlers. This demonstrates correct
knowledge.
Option B: Whole cow's milk can be introduced at 12 months of age in breastfed infants. This is correct.
Option C: Honey should NOT be given to infants before 12 months of age due to the risk of infant
botulism. The statement that honey can be given at 9 months indicates a knowledge deficit requiring
further teaching.
Option D: Small amounts (4 oz) of fruit juice in a cup are appropriate after 12 months of age. This shows
correct understanding.
7. The nurse is assessing a client at the scene of a mass casualty disaster and prioritizing care based on
the disaster triage tag system. The client who should be transported to the healthcare facility first is the
one:
a. Patient who is confused and has an open wound on the right lower leg
b. Patient who has multiple compound fracture and is reporting chest pain
c. Patient who reports an abdominal pain and has facial lacerations
d. Patient who has burns to 75% of the posterior trunk and lower body
ANSWER: B
Rationale:
Option A: Confusion with an open lower leg wound would likely be tagged yellow (delayed). The wound
is not immediately life-threatening.
Option B: Multiple compound fractures with chest pain suggests potential internal injuries and
compromised circulation/respiration. This client would be tagged red (immediate) and transported first
as they have life-threatening injuries that are treatable.
Option C: Abdominal pain and facial lacerations without other specified symptoms would likely be
tagged yellow (delayed) as these are not immediately life-threatening.
Option D: Burns to 75% of body surface area, especially in a mass casualty situation, would likely be
tagged black (expectant) as survival is unlikely despite treatment, and resources should be directed to
those with better prognosis.
