COMPREHENSIVE EXAM REVIEW NEWEST COMPLETE
REAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS (CORRECT VERIFIED ANSWERS) A NEW
UPDATED VERSION |GUARANTEED PASS.
Enalapril maleate is prescribed for a hospitalized client. Which assessment does the
nurse perform as a priority before administering the medication?
Checking the client's blood pressure
Checking the client's peripheral pulses
Checking the most recent potassium level
Checking the client's intake-and-output record for the last 24 hours - ANSWER:
Checking the client's blood pressure
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor
used to treat hypertension. One common side effect is postural hypotension.
Therefore the nurse would check the client's blood pressure immediately before
administering each dose. Checking the client's peripheral pulses, the results of the
most recent potassium level, and the intake and output for the previous 24 hours are
not specifically associated with this mediation.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse
provides instructions to the client about the test. Which statement by the client
indicates a need for further instruction?
"The test will take about 30 minutes."
"I need to fast for 8 hours before the test."
"I need to drink citrate of magnesia the night before the test and give myself a Fleet
enema on the morning of the test."
"I need to take a laxative after the test is completed, because the liquid that I'll have
to drink for the test can be constipating." - ANSWER: "I need to drink citrate of
magnesia the night before the test and give myself a Fleet enema on the morning of
the test."
Rationale: No special preparation is necessary before a GI series, except that NPO
(nothing by mouth) status must be maintained for 8 hours before the test. An upper
GI series involves visualization of the esophagus, duodenum, and upper jejunum by
means of the use of a contrast medium. It involves swallowing a contrast medium
(usually barium), which is administered in a flavored milkshake. Films are taken at
intervals during the test, which takes about 30 minutes. After an upper GI series, the
client is prescribed a laxative to hasten elimination of the barium. Barium that
remains in the colon may become hard and difficult to expel, leading to fecal
impaction.
,A nurse on the evening shift checks a primary health care provider's prescriptions
and notes that the dose of a prescribed medication is higher than the normal dose.
The nurse calls the primary health care provider's answering service and is told that
the primary health care provider is off for the night and will be available in the
morning. What should the nurse do next?
Call the nursing supervisor
Ask the answering service to contact the on-call primary health care provider
Withhold the medication until the primary health care provider can be reached in
the morning
Administer the medication but consult the primary health care provider when he
becomes available - ANSWER: Ask the answering service to contact the on-call
primary health care provider
Rationale: The nurse has a duty to protect the client from harm. A nurse who
believes that a primary health care provider's prescription may be in error is
responsible for clarifying the prescription before carrying it out. Therefore the nurse
would not administer the medication; instead, the nurse would withhold the
medication until the dose can be clarified. The nurse would not wait until the next
morning to obtain clarification. It is premature to call the nursing supervisor.
An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care
unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs)
on the monitor, checks the client's carotid pulse, and determines that the PVCs are
not perfusing. What is the nurse's most appropriate action?
Document the findings
Ask the ED primary health care provider to check the client
Continue to monitor the client's cardiac status
Inform the client that PVCs are expected after an MI - ANSWER: Ask the ED primary
health care provider to check the client
Rationale: The most appropriate action by the nurse would be to ask the ED health
care provider to check the client. PVCs are a result of increased irritability of
ventricular cells. Peripheral pulses may be absent or diminished with the PVCs
themselves because the decreased stroke volume of the premature beats may in
turn decrease peripheral perfusion. Because other rhythms also cause widened QRS
complexes, it is essential that the nurse determine whether the premature beats are
resulting in perfusion of the extremities. This is done by palpating the carotid,
brachial, or femoral artery while observing the monitor for widened complexes or by
auscultating for apical heart sounds. In the situation of acute MI, PVCs may be
considered warning dysrhythmias, possibly heralding the onset of ventricular
tachycardia or ventricular fibrillation. Therefore, the nurse would not tell the client
that the PVCs are expected. Although the nurse will continue to monitor the client
and document the findings, these are not the most appropriate actions of those
provided.
,NPO status is imposed 8 hours before the procedure on a client scheduled to
undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure,
the nurse checks the client's record and notes that the client routinely takes an oral
antihypertensive medication each morning. What action should the nurse take?
Administer the antihypertensive with a small sip of water
Withhold the antihypertensive and administer it at bedtime
Administer the medication by way of the intravenous (IV) route
Hold the antihypertensive and resume its administration on the day after the ECT -
ANSWER: Administer the antihypertensive with a small sip of water
Rationale: The nurse should administer the antihypertensive with a small sip of
water. General anesthesia is required for ECT, so NPO status is imposed for 6 to 8
hours before treatment to help prevent aspiration. Exceptions include clients who
routinely receive cardiac medications, antihypertensive agents, or histamine (H2)
blockers, which should be administered several hours before treatment with a small
sip of water. Withholding the antihypertensive and administering it at bedtime and
withholding the antihypertensive and resuming administration on the day after the
ECT are incorrect actions, because antihypertensives must be administered on time;
otherwise, the risk for rebound hypertension exists. The nurse would not administer
a medication by way of a route that has not been prescribed.
A client who recently underwent coronary artery bypass graft surgery comes to the
primary health care provider's office for a follow-up visit. On assessment, the client
tells the nurse that he is feeling depressed. Which response by the nurse is
therapeutic?
"Tell me more about what you're feeling."
"That's a normal response after this type of surgery."
"It will take time, but I promise you, you will get over this depression."
"Every client who has this surgery feels the same way for about a month." -
ANSWER: "Tell me more about what you're feeling."
Rationale: The therapeutic response by the nurse is, "Tell me more about what
you're feeling." When a client expresses feelings of depression, it is extremely
important for the nurse to further explore these feelings with the client. In stating,
"This is a normal response after this type of surgery" the nurse provides false
reassurance and avoids addressing the client's feelings. "It will take time, but I
promise you, you will get over the depression" is also a false reassurance, and it does
not encourage the expression of feelings. "Every client who has this surgery feels the
same way for about a month" is a generalization that avoids the client's feelings.
A client in labor experiences spontaneous rupture of the membranes. The nurse
immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the
amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which
action should be the nurse's priority?
, Contact the primary health care provider
Document the findings
Check the fluid for protein
Continue to monitor the client and the FHR - ANSWER: Contact the primary health
care provider
Rationale: The priority action is for the nurse to contact the primary health care
provider. The FHR is assessed for at least 1 minute when the membranes rupture.
The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid
should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or
strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis and
warrants notifying the primary health care provider. A large amount of vernix in the
fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be
seen in cases of postterm gestation or placental insufficiency. Checking the fluid for
protein is not associated with the data in the question. The nurse would continue to
monitor the client and the FHR and would document the findings.
A nurse has assisted a primary health care provider in inserting a central venous
access device into a client with a diagnosis of severe malnutrition who will be
receiving parenteral nutrition (PN). After insertion of the catheter what does the
nurse immediately do?
Call the radiography department to obtain a chest x-ray
Check the client's blood glucose level to serve as a baseline measurement
Hang the prescribed bag of PN and start the infusion at the prescribed rate
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain
patency - ANSWER: Call the radiography department to obtain a chest x-ray
Rationale: The nurse should immediately make arrangements to have a chest x-ray
done. One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the
catheter has been placed but before it is used for infusions, its placement must be
checked with an x-ray. Hanging the prescribed bag of PN and starting the infusion at
the prescribed rate and infusing normal saline solution through the catheter at a rate
of 100 mL/hr to maintain patency are all incorrect because they could result in the
infusion of solution into a lung if a pneumothorax is present. Although the nurse may
obtain a blood glucose measurement to serve as a baseline, this action is not the
priority.
A rape victim being treated in the emergency department says to the nurse, "I'm
really worried that I've got HIV now." What is the most appropriate response by the
nurse?
"HIV is rarely an issue in rape victims."
"Every rape victim is concerned about HIV."
"You're more likely to get pregnant than to contract HIV."
REAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS (CORRECT VERIFIED ANSWERS) A NEW
UPDATED VERSION |GUARANTEED PASS.
Enalapril maleate is prescribed for a hospitalized client. Which assessment does the
nurse perform as a priority before administering the medication?
Checking the client's blood pressure
Checking the client's peripheral pulses
Checking the most recent potassium level
Checking the client's intake-and-output record for the last 24 hours - ANSWER:
Checking the client's blood pressure
Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor
used to treat hypertension. One common side effect is postural hypotension.
Therefore the nurse would check the client's blood pressure immediately before
administering each dose. Checking the client's peripheral pulses, the results of the
most recent potassium level, and the intake and output for the previous 24 hours are
not specifically associated with this mediation.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse
provides instructions to the client about the test. Which statement by the client
indicates a need for further instruction?
"The test will take about 30 minutes."
"I need to fast for 8 hours before the test."
"I need to drink citrate of magnesia the night before the test and give myself a Fleet
enema on the morning of the test."
"I need to take a laxative after the test is completed, because the liquid that I'll have
to drink for the test can be constipating." - ANSWER: "I need to drink citrate of
magnesia the night before the test and give myself a Fleet enema on the morning of
the test."
Rationale: No special preparation is necessary before a GI series, except that NPO
(nothing by mouth) status must be maintained for 8 hours before the test. An upper
GI series involves visualization of the esophagus, duodenum, and upper jejunum by
means of the use of a contrast medium. It involves swallowing a contrast medium
(usually barium), which is administered in a flavored milkshake. Films are taken at
intervals during the test, which takes about 30 minutes. After an upper GI series, the
client is prescribed a laxative to hasten elimination of the barium. Barium that
remains in the colon may become hard and difficult to expel, leading to fecal
impaction.
,A nurse on the evening shift checks a primary health care provider's prescriptions
and notes that the dose of a prescribed medication is higher than the normal dose.
The nurse calls the primary health care provider's answering service and is told that
the primary health care provider is off for the night and will be available in the
morning. What should the nurse do next?
Call the nursing supervisor
Ask the answering service to contact the on-call primary health care provider
Withhold the medication until the primary health care provider can be reached in
the morning
Administer the medication but consult the primary health care provider when he
becomes available - ANSWER: Ask the answering service to contact the on-call
primary health care provider
Rationale: The nurse has a duty to protect the client from harm. A nurse who
believes that a primary health care provider's prescription may be in error is
responsible for clarifying the prescription before carrying it out. Therefore the nurse
would not administer the medication; instead, the nurse would withhold the
medication until the dose can be clarified. The nurse would not wait until the next
morning to obtain clarification. It is premature to call the nursing supervisor.
An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care
unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs)
on the monitor, checks the client's carotid pulse, and determines that the PVCs are
not perfusing. What is the nurse's most appropriate action?
Document the findings
Ask the ED primary health care provider to check the client
Continue to monitor the client's cardiac status
Inform the client that PVCs are expected after an MI - ANSWER: Ask the ED primary
health care provider to check the client
Rationale: The most appropriate action by the nurse would be to ask the ED health
care provider to check the client. PVCs are a result of increased irritability of
ventricular cells. Peripheral pulses may be absent or diminished with the PVCs
themselves because the decreased stroke volume of the premature beats may in
turn decrease peripheral perfusion. Because other rhythms also cause widened QRS
complexes, it is essential that the nurse determine whether the premature beats are
resulting in perfusion of the extremities. This is done by palpating the carotid,
brachial, or femoral artery while observing the monitor for widened complexes or by
auscultating for apical heart sounds. In the situation of acute MI, PVCs may be
considered warning dysrhythmias, possibly heralding the onset of ventricular
tachycardia or ventricular fibrillation. Therefore, the nurse would not tell the client
that the PVCs are expected. Although the nurse will continue to monitor the client
and document the findings, these are not the most appropriate actions of those
provided.
,NPO status is imposed 8 hours before the procedure on a client scheduled to
undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure,
the nurse checks the client's record and notes that the client routinely takes an oral
antihypertensive medication each morning. What action should the nurse take?
Administer the antihypertensive with a small sip of water
Withhold the antihypertensive and administer it at bedtime
Administer the medication by way of the intravenous (IV) route
Hold the antihypertensive and resume its administration on the day after the ECT -
ANSWER: Administer the antihypertensive with a small sip of water
Rationale: The nurse should administer the antihypertensive with a small sip of
water. General anesthesia is required for ECT, so NPO status is imposed for 6 to 8
hours before treatment to help prevent aspiration. Exceptions include clients who
routinely receive cardiac medications, antihypertensive agents, or histamine (H2)
blockers, which should be administered several hours before treatment with a small
sip of water. Withholding the antihypertensive and administering it at bedtime and
withholding the antihypertensive and resuming administration on the day after the
ECT are incorrect actions, because antihypertensives must be administered on time;
otherwise, the risk for rebound hypertension exists. The nurse would not administer
a medication by way of a route that has not been prescribed.
A client who recently underwent coronary artery bypass graft surgery comes to the
primary health care provider's office for a follow-up visit. On assessment, the client
tells the nurse that he is feeling depressed. Which response by the nurse is
therapeutic?
"Tell me more about what you're feeling."
"That's a normal response after this type of surgery."
"It will take time, but I promise you, you will get over this depression."
"Every client who has this surgery feels the same way for about a month." -
ANSWER: "Tell me more about what you're feeling."
Rationale: The therapeutic response by the nurse is, "Tell me more about what
you're feeling." When a client expresses feelings of depression, it is extremely
important for the nurse to further explore these feelings with the client. In stating,
"This is a normal response after this type of surgery" the nurse provides false
reassurance and avoids addressing the client's feelings. "It will take time, but I
promise you, you will get over the depression" is also a false reassurance, and it does
not encourage the expression of feelings. "Every client who has this surgery feels the
same way for about a month" is a generalization that avoids the client's feelings.
A client in labor experiences spontaneous rupture of the membranes. The nurse
immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the
amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which
action should be the nurse's priority?
, Contact the primary health care provider
Document the findings
Check the fluid for protein
Continue to monitor the client and the FHR - ANSWER: Contact the primary health
care provider
Rationale: The priority action is for the nurse to contact the primary health care
provider. The FHR is assessed for at least 1 minute when the membranes rupture.
The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid
should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or
strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis and
warrants notifying the primary health care provider. A large amount of vernix in the
fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be
seen in cases of postterm gestation or placental insufficiency. Checking the fluid for
protein is not associated with the data in the question. The nurse would continue to
monitor the client and the FHR and would document the findings.
A nurse has assisted a primary health care provider in inserting a central venous
access device into a client with a diagnosis of severe malnutrition who will be
receiving parenteral nutrition (PN). After insertion of the catheter what does the
nurse immediately do?
Call the radiography department to obtain a chest x-ray
Check the client's blood glucose level to serve as a baseline measurement
Hang the prescribed bag of PN and start the infusion at the prescribed rate
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain
patency - ANSWER: Call the radiography department to obtain a chest x-ray
Rationale: The nurse should immediately make arrangements to have a chest x-ray
done. One major complication associated with central venous catheter placement is
pneumothorax, which may result from accidental puncture of the lung. After the
catheter has been placed but before it is used for infusions, its placement must be
checked with an x-ray. Hanging the prescribed bag of PN and starting the infusion at
the prescribed rate and infusing normal saline solution through the catheter at a rate
of 100 mL/hr to maintain patency are all incorrect because they could result in the
infusion of solution into a lung if a pneumothorax is present. Although the nurse may
obtain a blood glucose measurement to serve as a baseline, this action is not the
priority.
A rape victim being treated in the emergency department says to the nurse, "I'm
really worried that I've got HIV now." What is the most appropriate response by the
nurse?
"HIV is rarely an issue in rape victims."
"Every rape victim is concerned about HIV."
"You're more likely to get pregnant than to contract HIV."
