COMPREHENSIVE EXAM PRACTICE
QUESTIONS WITH COMPLETE
ANSWERS
A nurse is caring for a newborn whose parent asks why her baby is receiving vitamin K.
The nurse should explain to the parents that the newborn should receive vitamin K to
prevent which of the following? - Answer-Bleeding
A charge nurse is observing a newly licensed nurse administer enteral feedings via NG
tube. Which of the following actions by the newly licensed nurse indicates an
understanding of the procedure? - Answer-Keeps the head of the bed elevated to 45°
for 1 hr after feedings.
A nurse is teaching a client about foods high in vitamin A. Which of the following foods
should the nurse recommend as having the highest amount of vitamin A? - Answer-1
medium raw carrot
An RN is planning care for a group of clients and is working with a licensed practical
nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the
RN delegate to the LPN? - Answer-
An RN is planning care for a group of clients and is working with a licensed practical
nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the
RN delegate to the LPN? - Answer-Insertion of a nasogastric tube
A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure.
Which of the following findings should indicate to the nurse that the client has the ability
to sign the informed consent? - Answer-The client is able to accurately describe the
upcoming procedure.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by
continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped
working. Which of the following actions should the nurse take while waiting for a new
infusion pump? - Answer-Provide dextrose 10% in water solution using manual drip
tubing at 60 mL/hr.
MY ANSWERThe nurse should use an infusion pump when administering TPN solution
to ensure accurate dosage and should taper the infusion rate before discontinuing the
solution to prevent hypoglycemia. If the nurse is unable to continue the TPN infusion by
infusion pump, the nurse should use manual drip tubing to infuse dextrose 10% in water
at the same rate as the TPN solution.
,A nurse is assessing a client who has schizophrenia and is taking chlorpromazine.
Which of the following findings is the priority for the nurse to report the provider? -
Answer-Temperature 39.4° C (103° F)
A nurse is teaching the parent of a school-age child about administering ear drops.
Which of the following responses by the parent indicates an understanding of the
teaching? - Answer-"I should pull the top of her ear upward and back while instilling the
medication."
A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the
following findings should the nurse expect? (Select all that apply.) - Answer-Facial
flushing is correct.
Nasal congestion is correct.
Headache is correct.
A nurse is caring for a client who has a deficit with cranial nerve (CN) II. Which of the
following actions should the nurse plan? - Answer-Clear objects from the client's walking
area.
A nurse is planning care for a client who has thrombocytopenia. Which of the following
instructions should the nurse include in the client's plan of care? - Answer-Avoid
venipunctures when possible.
A nurse in the delivery room is caring for a newborn immediately after birth. Which of
the following actions should the nurse take first? - Answer-Dry the newborn.
A nurse is assessing a newborn who was just admitted to the nursery and is sleeping.
For which of the following findings should the nurse intervene? - Answer-Axillary
temperature 36.2° C (97.2° F)
The expected reference range for the axillary temperature of a newborn is between
36.5° C and 37.5° C (97.7° F and 100° F). An axillary temperature of 36.2° C (97.2° F)
or below requires the nurse to intervene to prevent cold stress.
A nurse is assessing a client who has a stage II pressure ulcer. Which of the following
wound characteristics should the nurse expect? - Answer-Partial-thickness skin loss
A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following
actions should the nurse take? - Answer-Initiate oral rehydration therapy for the toddler.
A nurse is caring for a client who had a recent stoke. Prior to transferring the client to
the bedside commode, which of the following actions should the nurse take first? -
Answer-Assess the client for functional limitations.
A nurse is assessing a client who has schizophrenia. The nurse should identify the
following alteration in speech as which of the following? (Click on the audio button to
listen to the clip. - Answer-Clang association
, A nurse is counseling a couple who have been unsuccessful at conceiving for more
than a year. Which of the following statements should the nurse make to help the
couple cope with prolonged infertility? - Answer-"Would you like information regarding
some support groups?"
A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer.
When discussing the client's prognosis with her parents, the nurse should recognize
which of the following responses by the parents as an example of rationalization? -
Answer-"Maybe this is better for our child because we don't want her to suffer through
chemotherapy treatments."
A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following
actions should the nurse take? - Answer-Place the BP cuff in a labeled bag to send it for
decontamination.
A nurse is teaching the parents of a toddler about snacks. Which of the following foods
should the nurse recommend? - Answer-Steamed carrots
A nurse is providing teaching to a client who has hepatitis A. Which of the following
instructions should the nurse include? - Answer-Use a 1:100 chlorine bleach solution to
clean kitchen surfaces.
A nurse is providing teaching to a parent of a child who has a permanent tracheostomy
tube. Identify the sequence of steps the parent should follow to perform tracheostomy
care. (Move the steps into the box on the right, placing them in the selected order of
performance. Use all the steps.) - Answer-When teaching the parent to provide
tracheostomy care, the nurse should instruct the parent to first remove the inner
cannula. Next, the nurse should instruct the parent to remove the soiled dressing and
then clean the stoma with sterile saline. Finally, the nurse should instruct the parent to
change the tracheostomy collar.
A nurse is providing discharge instructions to a client who has a new prescription for
warfarin. Which of the following client statements should the nurse identify as an
indication that the client understands the teaching? - Answer-"I should report a change
in the color of my stools."
A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the
following clinical manifestations should the nurse expect? - Answer-Grandiose thoughts
A nurse is planning to teach a client who is to start a new prescription for fluoxetine. For
which of the following findings should the nurse instruct the client to monitor and report
to the provider? - Answer-Tremors
Fluoxetine can cause serotonin syndrome within 2 to 72 hr after starting treatment. The
client can experience tremors, agitation, confusion, anxiety, and hallucinations. The
QUESTIONS WITH COMPLETE
ANSWERS
A nurse is caring for a newborn whose parent asks why her baby is receiving vitamin K.
The nurse should explain to the parents that the newborn should receive vitamin K to
prevent which of the following? - Answer-Bleeding
A charge nurse is observing a newly licensed nurse administer enteral feedings via NG
tube. Which of the following actions by the newly licensed nurse indicates an
understanding of the procedure? - Answer-Keeps the head of the bed elevated to 45°
for 1 hr after feedings.
A nurse is teaching a client about foods high in vitamin A. Which of the following foods
should the nurse recommend as having the highest amount of vitamin A? - Answer-1
medium raw carrot
An RN is planning care for a group of clients and is working with a licensed practical
nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the
RN delegate to the LPN? - Answer-
An RN is planning care for a group of clients and is working with a licensed practical
nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the
RN delegate to the LPN? - Answer-Insertion of a nasogastric tube
A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure.
Which of the following findings should indicate to the nurse that the client has the ability
to sign the informed consent? - Answer-The client is able to accurately describe the
upcoming procedure.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) solution by
continuous IV infusion at 60 mL/hr. The nurse discovers the infusion pump has stopped
working. Which of the following actions should the nurse take while waiting for a new
infusion pump? - Answer-Provide dextrose 10% in water solution using manual drip
tubing at 60 mL/hr.
MY ANSWERThe nurse should use an infusion pump when administering TPN solution
to ensure accurate dosage and should taper the infusion rate before discontinuing the
solution to prevent hypoglycemia. If the nurse is unable to continue the TPN infusion by
infusion pump, the nurse should use manual drip tubing to infuse dextrose 10% in water
at the same rate as the TPN solution.
,A nurse is assessing a client who has schizophrenia and is taking chlorpromazine.
Which of the following findings is the priority for the nurse to report the provider? -
Answer-Temperature 39.4° C (103° F)
A nurse is teaching the parent of a school-age child about administering ear drops.
Which of the following responses by the parent indicates an understanding of the
teaching? - Answer-"I should pull the top of her ear upward and back while instilling the
medication."
A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the
following findings should the nurse expect? (Select all that apply.) - Answer-Facial
flushing is correct.
Nasal congestion is correct.
Headache is correct.
A nurse is caring for a client who has a deficit with cranial nerve (CN) II. Which of the
following actions should the nurse plan? - Answer-Clear objects from the client's walking
area.
A nurse is planning care for a client who has thrombocytopenia. Which of the following
instructions should the nurse include in the client's plan of care? - Answer-Avoid
venipunctures when possible.
A nurse in the delivery room is caring for a newborn immediately after birth. Which of
the following actions should the nurse take first? - Answer-Dry the newborn.
A nurse is assessing a newborn who was just admitted to the nursery and is sleeping.
For which of the following findings should the nurse intervene? - Answer-Axillary
temperature 36.2° C (97.2° F)
The expected reference range for the axillary temperature of a newborn is between
36.5° C and 37.5° C (97.7° F and 100° F). An axillary temperature of 36.2° C (97.2° F)
or below requires the nurse to intervene to prevent cold stress.
A nurse is assessing a client who has a stage II pressure ulcer. Which of the following
wound characteristics should the nurse expect? - Answer-Partial-thickness skin loss
A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following
actions should the nurse take? - Answer-Initiate oral rehydration therapy for the toddler.
A nurse is caring for a client who had a recent stoke. Prior to transferring the client to
the bedside commode, which of the following actions should the nurse take first? -
Answer-Assess the client for functional limitations.
A nurse is assessing a client who has schizophrenia. The nurse should identify the
following alteration in speech as which of the following? (Click on the audio button to
listen to the clip. - Answer-Clang association
, A nurse is counseling a couple who have been unsuccessful at conceiving for more
than a year. Which of the following statements should the nurse make to help the
couple cope with prolonged infertility? - Answer-"Would you like information regarding
some support groups?"
A nurse is caring for an adolescent client who has a new diagnosis of terminal cancer.
When discussing the client's prognosis with her parents, the nurse should recognize
which of the following responses by the parents as an example of rationalization? -
Answer-"Maybe this is better for our child because we don't want her to suffer through
chemotherapy treatments."
A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following
actions should the nurse take? - Answer-Place the BP cuff in a labeled bag to send it for
decontamination.
A nurse is teaching the parents of a toddler about snacks. Which of the following foods
should the nurse recommend? - Answer-Steamed carrots
A nurse is providing teaching to a client who has hepatitis A. Which of the following
instructions should the nurse include? - Answer-Use a 1:100 chlorine bleach solution to
clean kitchen surfaces.
A nurse is providing teaching to a parent of a child who has a permanent tracheostomy
tube. Identify the sequence of steps the parent should follow to perform tracheostomy
care. (Move the steps into the box on the right, placing them in the selected order of
performance. Use all the steps.) - Answer-When teaching the parent to provide
tracheostomy care, the nurse should instruct the parent to first remove the inner
cannula. Next, the nurse should instruct the parent to remove the soiled dressing and
then clean the stoma with sterile saline. Finally, the nurse should instruct the parent to
change the tracheostomy collar.
A nurse is providing discharge instructions to a client who has a new prescription for
warfarin. Which of the following client statements should the nurse identify as an
indication that the client understands the teaching? - Answer-"I should report a change
in the color of my stools."
A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the
following clinical manifestations should the nurse expect? - Answer-Grandiose thoughts
A nurse is planning to teach a client who is to start a new prescription for fluoxetine. For
which of the following findings should the nurse instruct the client to monitor and report
to the provider? - Answer-Tremors
Fluoxetine can cause serotonin syndrome within 2 to 72 hr after starting treatment. The
client can experience tremors, agitation, confusion, anxiety, and hallucinations. The
