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RN Comprehensive Predictor 2019 Form C
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A nurse is caring for a client who has bipolar disorder and is experiencing
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acute mania. The nurse obtained a verbal prescription for restraints. Which
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of the following should the actions the nurse take?
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A. Request a renewal of the prescription every 8 hr.
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B. Check the client’s peripheral pulse rate every 30 min
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C. Obtain a prescription for restraint within 4 hr.
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D. Document the client’s condition every 15 minutes
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1. A nursing planning care for a school-age child who is 4 hr
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postoperative following perforated appendicitis. Which of the following
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actions should the nurse include in the plan of care?
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a. Offer small amounts of clear liquids 6 hr following surgery (assess for
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gag reflex first)
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b. Give cromolyn nebulizer solution every 6 hr (for asthma)
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c. Apply a warm compress to the operative site every 4 hr
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d. Administer analgesics on a scheduled basis for the first 24 hr
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2. A nurse is receiving change-of-shift report for a group of clients.
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Which of the following clients should the nurse plan to assess first?
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a. A client who has sinus arrhythmia and is receiving cardiac monitoring
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b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
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c. A client who has epidural analgesia and weakness in the lower
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extremities
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d. A client who has a hip fracture and a new onset of tachypnea
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3. A nurse is preparing to apply a transdermal nicotine patch for a
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client. Which of the following actions should the nurse tak e?
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a. Shave hairy areas of skin prior to application (apply to hairless, clean &
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dry areas to promote absorption; avoid oily or broken skin)
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b. Wear gloves to apply the patch to the client’s skin
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c. Apply the patch within 1 hr of removing it from the protective pouch
(apply immediately)
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d. Remove the previous patch and place it in a tissue (fold patch in
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half with sticky sides pressed together)
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4. A nurse has just received change-of-shift report for four clients.
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Which of the following clients should the nurse assess first?
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a. A client who was just given a glass of orange juice for a low blood
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glucose level
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b. A client who is schedule for a procedure in 1 hr (can wait)
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c. A client who has 100 mL fluid remaining in his IV bag (can wait)
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d. A client who received a pain medication 30 min ago for postoperative
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pain
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5. A nurse is caring for a client who is receiving intermittent enteral
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tube feedings. Which of the following places the client at risk for
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aspiration?
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a. A history of gastroesophageal reflux disease
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b. Receiving a high osmolarity formula
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c. Sitting in a high-Fowler’s position during the feeding
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d. A residual of 65 mL 1hr postprandial
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6. A nurse is reviewing the laboratory results for a client who has
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Cushing’s disease. The nurse should expect the client to have an increase
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in which of the following laboratory values? a. Serum glucose level-
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increased
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b. Serum calcium level-decreased
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c. Lymphocyte count- decreased immune system.
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d. Serum potassium level- decreased
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. 8. A nurse is caring for a client who has severe preeclampsia and is
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receiving magnesium sulfate intravenously. The nurse discontinues the
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magnesium sulfate after the client displaces toxicity. Which of the
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following actions should the nurse take?
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a. Position the client supine
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b. Prepare an IV bolus of dextrose 5% in water
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c. Administer methylergonovine IM
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d. Administer calcium gluconate IV
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Calcium gluconate is given for magnesium sulfate toxicity. Always have an
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injectable form of calcium gluconate available when administering
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magnesium sulfate by IV.
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9. A charge nurse is teaching new staff members about factors that
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increase a client’s risk to become violent. Which of the following risk factors
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should the nurse include as the best predictor of future violence?
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a. Experiencing delusions
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b. Male gender
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c. Previous violent behavior
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d. A history of being in prison
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Risk factors also include: past history of aggression, poor impulse control,
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and violence. Comorbidity that leads to acts of violence (psychotic
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delusions, command hallucinations, violent angry reactions with cognitive
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disorders).
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Individual Assessment for Violence
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10. A nurse is preparing to perform a sterile dressing change. Which of
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the following actions should the nurse take when setting up the sterile
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field?
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a. Place the cap from the solution sterile side up on clean surface
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b. Open the outermost flap of the sterile kit toward the body→ flap
AWAY from the body's first
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c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the
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sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap
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that is considered contaminated.
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Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW
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waist level; should be ABOVE waist level
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11. A nurse is providing teaching to an older adult client about methods
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to promote nighttime sleep. Which of the following instructions should the
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nurse include?
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ne
a. Eat a light snack before bedtime
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b. Stay in bed at least 1 hr if unable to fall asleep
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c. Take a 1 hr nap during the day
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d. Perform exercises prior to bedtime
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12. A home health nurse is preparing for an initial visit with an older
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adult client who lives alone. Which of the following actions should the
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nurse take first?
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a. Educate the client about current medical diagnosis
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b. Refer the client to a meal delivery program
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c. Identify environmental hazards in the home
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sh
ne
la
tz
RN Comprehensive Predictor 2019 Form C
sh
Sp
ne
la
tz
A nurse is caring for a client who has bipolar disorder and is experiencing
sh
Sp
ne
acute mania. The nurse obtained a verbal prescription for restraints. Which
la
of the following should the actions the nurse take?
tz
sh
A. Request a renewal of the prescription every 8 hr.
Sp
ne
B. Check the client’s peripheral pulse rate every 30 min
la
C. Obtain a prescription for restraint within 4 hr.
tz
sh
Sp
D. Document the client’s condition every 15 minutes
ne
1. A nursing planning care for a school-age child who is 4 hr
la
tz
postoperative following perforated appendicitis. Which of the following
sh
Sp
ne
actions should the nurse include in the plan of care?
la
a. Offer small amounts of clear liquids 6 hr following surgery (assess for
tz
sh
gag reflex first)
Sp
ne
b. Give cromolyn nebulizer solution every 6 hr (for asthma)
la
c. Apply a warm compress to the operative site every 4 hr
tz
sh
Sp
d. Administer analgesics on a scheduled basis for the first 24 hr
ne
2. A nurse is receiving change-of-shift report for a group of clients.
la
tz
Which of the following clients should the nurse plan to assess first?
sh
Sp
ne
a. A client who has sinus arrhythmia and is receiving cardiac monitoring
la
b. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%
tz
sh
c. A client who has epidural analgesia and weakness in the lower
Sp
ne
extremities
la
d. A client who has a hip fracture and a new onset of tachypnea
tz
sh
Sp
ne
3. A nurse is preparing to apply a transdermal nicotine patch for a
la
tz
client. Which of the following actions should the nurse tak e?
sh
Sp
ne
a. Shave hairy areas of skin prior to application (apply to hairless, clean &
la
dry areas to promote absorption; avoid oily or broken skin)
sh
b. Wear gloves to apply the patch to the client’s skin
Sp
la
Sp
, ne
tz
sh
ne
c. Apply the patch within 1 hr of removing it from the protective pouch
(apply immediately)
la
tz
sh
d. Remove the previous patch and place it in a tissue (fold patch in
Sp
ne
half with sticky sides pressed together)
la
4. A nurse has just received change-of-shift report for four clients.
tz
sh
Sp
Which of the following clients should the nurse assess first?
ne
a. A client who was just given a glass of orange juice for a low blood
la
tz
glucose level
sh
Sp
ne
b. A client who is schedule for a procedure in 1 hr (can wait)
la
c. A client who has 100 mL fluid remaining in his IV bag (can wait)
tz
sh
d. A client who received a pain medication 30 min ago for postoperative
Sp
ne
pain
la
tz
5. A nurse is caring for a client who is receiving intermittent enteral
sh
Sp
tube feedings. Which of the following places the client at risk for
ne
aspiration?
la
tz
a. A history of gastroesophageal reflux disease
sh
Sp
ne
b. Receiving a high osmolarity formula
la
c. Sitting in a high-Fowler’s position during the feeding
tz
sh
Sp
d. A residual of 65 mL 1hr postprandial
ne
6. A nurse is reviewing the laboratory results for a client who has
la
tz
Cushing’s disease. The nurse should expect the client to have an increase
sh
Sp
in which of the following laboratory values? a. Serum glucose level-
ne
increased
la
tz
sh
Sp
ne
la
tz
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Sp
ne
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, ne
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b. Serum calcium level-decreased
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c. Lymphocyte count- decreased immune system.
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Sp
d. Serum potassium level- decreased
ne
. 8. A nurse is caring for a client who has severe preeclampsia and is
la
tz
receiving magnesium sulfate intravenously. The nurse discontinues the
sh
Sp
magnesium sulfate after the client displaces toxicity. Which of the
ne
la
following actions should the nurse take?
tz
sh
a. Position the client supine
Sp
ne
b. Prepare an IV bolus of dextrose 5% in water
la
c. Administer methylergonovine IM
tz
sh
Sp
d. Administer calcium gluconate IV
ne
Calcium gluconate is given for magnesium sulfate toxicity. Always have an
la
tz
injectable form of calcium gluconate available when administering
sh
Sp
magnesium sulfate by IV.
ne
la
tz
sh
9. A charge nurse is teaching new staff members about factors that
Sp
ne
increase a client’s risk to become violent. Which of the following risk factors
la
should the nurse include as the best predictor of future violence?
tz
sh
Sp
a. Experiencing delusions
ne
b. Male gender
la
c. Previous violent behavior
tz
sh
Sp
d. A history of being in prison
ne
Risk factors also include: past history of aggression, poor impulse control,
la
tz
and violence. Comorbidity that leads to acts of violence (psychotic
sh
Sp
delusions, command hallucinations, violent angry reactions with cognitive
ne
disorders).
la
tz
sh
Individual Assessment for Violence
Sp
ne
la
10. A nurse is preparing to perform a sterile dressing change. Which of
tz
sh
Sp
the following actions should the nurse take when setting up the sterile
ne
field?
la
a. Place the cap from the solution sterile side up on clean surface
sh
Sp
b. Open the outermost flap of the sterile kit toward the body→ flap
AWAY from the body's first
la
Sp
, ne
tz
sh
ne
c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the
la
sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap
tz
sh
that is considered contaminated.
Sp
d. ne
Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW
la
waist level; should be ABOVE waist level
tz
sh
Sp
11. A nurse is providing teaching to an older adult client about methods
ne
to promote nighttime sleep. Which of the following instructions should the
la
tz
nurse include?
sh
Sp
ne
a. Eat a light snack before bedtime
la
b. Stay in bed at least 1 hr if unable to fall asleep
tz
sh
c. Take a 1 hr nap during the day
Sp
ne
d. Perform exercises prior to bedtime
la
12. A home health nurse is preparing for an initial visit with an older
tz
sh
Sp
adult client who lives alone. Which of the following actions should the
ne
nurse take first?
la
tz
a. Educate the client about current medical diagnosis
sh
Sp
ne
b. Refer the client to a meal delivery program
la
c. Identify environmental hazards in the home
tz
sh
Sp
ne
la
tz
sh
Sp
ne
la
tz
sh
Sp
ne
la
tz
sh
Sp
ne
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