PN COMPREHENSIVE PROCTORED EXAM WITH VERIFIED
QUESTION AND ANSWERS.
A nurse is assisting in the care of a client who is 1 hr postpartum.
Exhibit 1
Nurses' Notes
1200:
Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above
the umbilicus.Oxytocin 20 units being administered via continuous IV infusion
1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin
cool and clammy. Provider notified.
Exhibit 2
Vital Signs
1200:
Temperature 37.5° C (99.5° F)Heart rate 92/minRespiratory
Select the 6 actions the nurse should take.
Weigh the perineal pads.
Insert an indwelling urinary catheter.
Administer methylergonovine.
Provide emotional support.
Administer oxygen at 12 L/min via nonrebreather face mask.
Firmly massage the uterine fundus.
When taking action for the client, the nurse should firmly massage the uterine fundus, administer
methylergonovine, weigh the perineal pads, provide emotional support, insert an indwelling
urinary catheter, and administer oxygen at 12 L/min via nonrebreather face mask. The nurse
should identify that the client is experiencing a postpartum hemorrhage, which requires
immediate intervention to prevent hemorrhagic shock.
A nurse is collecting data from a client who is scheduled for surgery.
Exhibit 1
Vital Signs
0630:
Temperature 36.9° C (98.5° F)Heart rate 74/minRespiratory rate 20/minBlood pressure 122/76
mmHgOxygen saturation 96% on room air
0730:
Temperature 36.9° C (98.5° F)Heart rate 76/minRespiratory rate 20/minBlood pressure 128/78
mmHgOxygen saturation 95% on room air
Exhibit 2
Nurses' Notes
0630:
Client reports restlessness and inability to sleep more than 3 to 4 hr per night for the last week.
Cli
,Click to highlight the data collection findings that the nurse should report to the provider prior to
the procedure. To deselect a finding, click on the finding again.
Hemoglobin level
Allergy
Family history
When collecting data from the client and analyzing cues, the nurse should determine the client's
hemoglobin level, latex allergy, and family history of malignant hyperthermia should be reported
to the provider. When the client's hemoglobin level is below the expected range, the client might
require blood products during the intraoperative phase. The client's allergy to avocados and
bananas can indicate an allergy to latex products and should be reported to the provider. The
surgical team will need to remove all latex products from the operating room. During the
intraoperative phase, the nurses must be diligent in monitoring the client's vital signs and
laboratory values, especially in a client who has a family history of malignant hyperthermia.
A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty using
eating utensils. The nurse should identify the need for a referral to which of the following
interprofessional team members?
Occupational therapist
The nurse should identify the need for a referral to an occupational therapist to teach the client
how to use special eating utensils.
A nurse is reviewing the electronic health records of four clients. Which of the following client
conditions should the nurse recognize as reportable to a regulatory agency?
A client who is newly diagnosed with tuberculosis
The nurse should identify that certain communicable diseases, such as tuberculosis, require
notification of the local and state health departments.
A nurse is caring for a client who is being discharged home following a cerebrovascular
accident. Which of the following documents should the nurse plan to include with the discharge
report?
List of potential complications to report
Discharge instructions are defined as any form of documentation provided to the client, upon
discharge to home, which facilitates safe and appropriate continuity of care. The nurse should
plan to include a list of potential complications that should be reported to the provider in the
client's discharge instructions.
A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance.
Which of the following statements by the parent indicates an understanding of the teaching?
"I should offer my child yogurt that has a probiotic as a snack."
Children who have lactose intolerance should be offered dairy products that have a probiotic,
such as lactobacillus. The probiotic promotes tolerance of lactose in the colon.
,A nurse is reinforcing teaching for a client who has type 1 diabetes mellitus. Which of the
following client statements indicates an understanding of the teaching?
"I should check my blood sugar if my appetite is decreased."
The nurse should instruct the client to monitor blood glucose levels closely. Change in appetite
can be an early sign of hyperglycemia and inadequate intake may cause blood glucose to drop.
A nurse is collecting data from a client who has iron deficiency anemia. Which of the following
findings should the nurse expect?
Difficulty concentrating
In clients who have iron deficiency anemia, body cells do not receive the required oxygen
because there is less hemoglobin for binding. The nurse should recognize that impaired
oxygenation of brain tissue can lead to dizziness and difficulty concentrating.
A nurse is caring for a client who is immunocompromised. Which of the following
immunizations is contraindicated?
Measles, mumps, and rubella (MMR)
The MMR vaccine consists of a live virus and is contraindicated for a client who is
immunocompromised.
A nurse is caring for a client who has expressive aphasia following a stroke. Which of the
following methods should the nurse use when communicating with the client?
Provide a picture board.
A client who has expressive aphasia has difficulty expressing needs or wants through
verbalization or writing. The use of a picture board provides an alternative means of
communication that might be less frustrating for the client.
A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After
drawing up the medication, the nurse accidentally brushes the needle on the counter's surface.
Which of the following actions should the nurse take?
Prepare a new dose of insulin for injection.
Insulin is administered using an insulin syringe with a preattached needle. Therefore, to ensure
the sterility of the needle, the nurse should prepare a new dose of insulin for injection using a
new syringe and new dose of insulin.
A nurse is checking the reflexes of a newborn. Which of the following techniques should the
nurse use to elicit the Babinski reflex?
Stroke the sole of the newborn's foot upward and toward the great toe.
The nurse should stroke upward along the lateral aspect of the sole of the foot, beginning at the
heel, to elicit the Babinski reflex.
A nurse is administering morning medications to a client. The client questions the nurse
regarding a medication that they do not recognize. Which of the following actions should the
nurse take first?
, Verify the prescription in the client's medical record.
The first action the nurse should take when using the nursing process is to collect more data. By
verifying the prescription in the client's medical record, the nurse can ensure that the medication
is prescribed for the client.
We have an expert-written solution to this problem!
A client in a mental health facility accuses a nurse of stealing money from their room. Which of
the following therapeutic responses should the nurse make?
Tell me how you decided who took your money."
This response by the nurse is an example of therapeutic communication, in which the nurse
validates the client's concern by encouraging them to describe their perception
A nurse is reinforcing teaching for a client who is preparing to return to work after a back injury.
Which of the following instructions for safe lifting technique should the nurse include?
"You should hold a box close to your body when lifting it up."
The client should hold the box as close to their body as possible to maintain balance and prevent
injury.
A nurse is instructing an assistive personnel (AP) about caring for a client who has hepatitis A
and is incontinent of stool. Which of the following infection control precautions should the nurse
instruct the AP to use?
Contact
Hepatitis A is spread by the fecal-oral route. Standard precautions are usually sufficient to
prevent the spread of infection. However, if the client who has hepatitis A is also incontinent of
stool, then contact precautions are indicated.
A nurse is collecting data from a client who has multiple sclerosis. Which of the following
findings should the nurse expect?
Ataxia
The nurse should expect a client who has multiple sclerosis to manifest ataxia, which is a lack of
coordination and movement. Other manifestations include fatigue, impaired memory, diplopia,
and bowel and bladder incontinence.
A nurse is caring for a client who is crying and states their provider informed them that they have
a tumor and will need a biopsy. Which of the following responses should the nurse make?
"What have you done to help yourself get through stressful situations before?"
This is a therapeutic response. The nurse is aware the client is under stress and encourages
comparison to investigate whether they have experience dealing with a stressful situation.
QUESTION AND ANSWERS.
A nurse is assisting in the care of a client who is 1 hr postpartum.
Exhibit 1
Nurses' Notes
1200:
Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above
the umbilicus.Oxytocin 20 units being administered via continuous IV infusion
1215:
Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin
cool and clammy. Provider notified.
Exhibit 2
Vital Signs
1200:
Temperature 37.5° C (99.5° F)Heart rate 92/minRespiratory
Select the 6 actions the nurse should take.
Weigh the perineal pads.
Insert an indwelling urinary catheter.
Administer methylergonovine.
Provide emotional support.
Administer oxygen at 12 L/min via nonrebreather face mask.
Firmly massage the uterine fundus.
When taking action for the client, the nurse should firmly massage the uterine fundus, administer
methylergonovine, weigh the perineal pads, provide emotional support, insert an indwelling
urinary catheter, and administer oxygen at 12 L/min via nonrebreather face mask. The nurse
should identify that the client is experiencing a postpartum hemorrhage, which requires
immediate intervention to prevent hemorrhagic shock.
A nurse is collecting data from a client who is scheduled for surgery.
Exhibit 1
Vital Signs
0630:
Temperature 36.9° C (98.5° F)Heart rate 74/minRespiratory rate 20/minBlood pressure 122/76
mmHgOxygen saturation 96% on room air
0730:
Temperature 36.9° C (98.5° F)Heart rate 76/minRespiratory rate 20/minBlood pressure 128/78
mmHgOxygen saturation 95% on room air
Exhibit 2
Nurses' Notes
0630:
Client reports restlessness and inability to sleep more than 3 to 4 hr per night for the last week.
Cli
,Click to highlight the data collection findings that the nurse should report to the provider prior to
the procedure. To deselect a finding, click on the finding again.
Hemoglobin level
Allergy
Family history
When collecting data from the client and analyzing cues, the nurse should determine the client's
hemoglobin level, latex allergy, and family history of malignant hyperthermia should be reported
to the provider. When the client's hemoglobin level is below the expected range, the client might
require blood products during the intraoperative phase. The client's allergy to avocados and
bananas can indicate an allergy to latex products and should be reported to the provider. The
surgical team will need to remove all latex products from the operating room. During the
intraoperative phase, the nurses must be diligent in monitoring the client's vital signs and
laboratory values, especially in a client who has a family history of malignant hyperthermia.
A nurse is caring for a client who is recovering from a stroke and is experiencing difficulty using
eating utensils. The nurse should identify the need for a referral to which of the following
interprofessional team members?
Occupational therapist
The nurse should identify the need for a referral to an occupational therapist to teach the client
how to use special eating utensils.
A nurse is reviewing the electronic health records of four clients. Which of the following client
conditions should the nurse recognize as reportable to a regulatory agency?
A client who is newly diagnosed with tuberculosis
The nurse should identify that certain communicable diseases, such as tuberculosis, require
notification of the local and state health departments.
A nurse is caring for a client who is being discharged home following a cerebrovascular
accident. Which of the following documents should the nurse plan to include with the discharge
report?
List of potential complications to report
Discharge instructions are defined as any form of documentation provided to the client, upon
discharge to home, which facilitates safe and appropriate continuity of care. The nurse should
plan to include a list of potential complications that should be reported to the provider in the
client's discharge instructions.
A nurse is reinforcing teaching with the parent of a preschooler who has lactose intolerance.
Which of the following statements by the parent indicates an understanding of the teaching?
"I should offer my child yogurt that has a probiotic as a snack."
Children who have lactose intolerance should be offered dairy products that have a probiotic,
such as lactobacillus. The probiotic promotes tolerance of lactose in the colon.
,A nurse is reinforcing teaching for a client who has type 1 diabetes mellitus. Which of the
following client statements indicates an understanding of the teaching?
"I should check my blood sugar if my appetite is decreased."
The nurse should instruct the client to monitor blood glucose levels closely. Change in appetite
can be an early sign of hyperglycemia and inadequate intake may cause blood glucose to drop.
A nurse is collecting data from a client who has iron deficiency anemia. Which of the following
findings should the nurse expect?
Difficulty concentrating
In clients who have iron deficiency anemia, body cells do not receive the required oxygen
because there is less hemoglobin for binding. The nurse should recognize that impaired
oxygenation of brain tissue can lead to dizziness and difficulty concentrating.
A nurse is caring for a client who is immunocompromised. Which of the following
immunizations is contraindicated?
Measles, mumps, and rubella (MMR)
The MMR vaccine consists of a live virus and is contraindicated for a client who is
immunocompromised.
A nurse is caring for a client who has expressive aphasia following a stroke. Which of the
following methods should the nurse use when communicating with the client?
Provide a picture board.
A client who has expressive aphasia has difficulty expressing needs or wants through
verbalization or writing. The use of a picture board provides an alternative means of
communication that might be less frustrating for the client.
A nurse is preparing to administer insulin to a client who has type 1 diabetes mellitus. After
drawing up the medication, the nurse accidentally brushes the needle on the counter's surface.
Which of the following actions should the nurse take?
Prepare a new dose of insulin for injection.
Insulin is administered using an insulin syringe with a preattached needle. Therefore, to ensure
the sterility of the needle, the nurse should prepare a new dose of insulin for injection using a
new syringe and new dose of insulin.
A nurse is checking the reflexes of a newborn. Which of the following techniques should the
nurse use to elicit the Babinski reflex?
Stroke the sole of the newborn's foot upward and toward the great toe.
The nurse should stroke upward along the lateral aspect of the sole of the foot, beginning at the
heel, to elicit the Babinski reflex.
A nurse is administering morning medications to a client. The client questions the nurse
regarding a medication that they do not recognize. Which of the following actions should the
nurse take first?
, Verify the prescription in the client's medical record.
The first action the nurse should take when using the nursing process is to collect more data. By
verifying the prescription in the client's medical record, the nurse can ensure that the medication
is prescribed for the client.
We have an expert-written solution to this problem!
A client in a mental health facility accuses a nurse of stealing money from their room. Which of
the following therapeutic responses should the nurse make?
Tell me how you decided who took your money."
This response by the nurse is an example of therapeutic communication, in which the nurse
validates the client's concern by encouraging them to describe their perception
A nurse is reinforcing teaching for a client who is preparing to return to work after a back injury.
Which of the following instructions for safe lifting technique should the nurse include?
"You should hold a box close to your body when lifting it up."
The client should hold the box as close to their body as possible to maintain balance and prevent
injury.
A nurse is instructing an assistive personnel (AP) about caring for a client who has hepatitis A
and is incontinent of stool. Which of the following infection control precautions should the nurse
instruct the AP to use?
Contact
Hepatitis A is spread by the fecal-oral route. Standard precautions are usually sufficient to
prevent the spread of infection. However, if the client who has hepatitis A is also incontinent of
stool, then contact precautions are indicated.
A nurse is collecting data from a client who has multiple sclerosis. Which of the following
findings should the nurse expect?
Ataxia
The nurse should expect a client who has multiple sclerosis to manifest ataxia, which is a lack of
coordination and movement. Other manifestations include fatigue, impaired memory, diplopia,
and bowel and bladder incontinence.
A nurse is caring for a client who is crying and states their provider informed them that they have
a tumor and will need a biopsy. Which of the following responses should the nurse make?
"What have you done to help yourself get through stressful situations before?"
This is a therapeutic response. The nurse is aware the client is under stress and encourages
comparison to investigate whether they have experience dealing with a stressful situation.
