COMPREHENSIVE EXAM FORM B ASSURED SUCCESS

• A nurse in a long-term care facility is assisting with an in- service for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assault? ANS: Informing a client the nurse is going to administer an injection even though the client refuses . • A nurse is collecting data from who is severe pain. Which ofIthe following questions should the nurse ask first? ANS: "Where is your pain located?" • A nurse is reviewing the laboratory results for a client who is at29 weeks gestation. For which of the following results should the nurse notify the provider? ANS: Platelet count 95,000 mm3 • A nurse is performing a dressing change for a client who had abdominal surgery 5 day s ago. The nurse notes organs protruding from the incision. Which of the following act ions should the nurse take? ANS: Cover the exposed area with sterile, saline-soaked dressings. • A nurse is speaking with the adult daughter of a client who has Alzheimer's disease. T he daughter states, "I love my dad, but caring for him is wearing me out." Which of the following response should the nurse make? ANS: "Let's discuss how caring for your father is a following affecting your health. • A nurse is contributing to the plan of care for a care for a client who has chest tube connected to a closed drainage system. Which of the following actions should the nurse include in the plan of care? ANS: Maintain the drainage system below the level of the client's chest. • A nurse in an acute mental health facility is caring for a client who has borderline personality disorder and reports. "I am going to kill my girlfriend when I get out of here." Which of the following actions should the nurse take? ANS: Notify the client's care team of the threats against the partner • A nurse is admitting a client who is at high risk for suicide Which of the following actions is the nurse's priority? ANS: Search the client's personal belongings • A nurse is caring for a client who is 1 day postoperative and is unable to ambulate. Which of the following actions should the nurse take to promote the client's venous return? ANS: Maintain the sequential compression device. • A nurse on an acute care unity is collecting data from a school-age Child who has cystic fibrosis. Which ofIthe followingfindings is the priority for the nurse? ANS: Reports lack of appetite • a nurse working in a provider's following ice receives a phone call from the parent of a school age child who has varicella. The parent asked the nurse when the child can return to school. Which of the following responses should the nurse make? ANS: "When the lesions have scabbed over." • A nurse in a pediatric clinic is collecting the data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take? ANS: Report the suspected abuse to a appropriate agency. • A nurse is collecting data from a middle adult female client who is taking melatonin .Which of the following responses to the med should the nurse expect? ANS: Improved sleep • A nurse on a pediatric unit is collecting data from four newly admitted clients. Which of the following clients should the nurse identify as being at risk for urinary retention? ANS: A school age child who has allergic rhinitis and is taking diphenhydramine.