Comprehensive Exam B Questions
with Verified Answers
A client is rushed to the emergency department by friends, who tell the nurse "We think
our friend overdosed on heroin." The client is not breathing. There are fresh needle
marks on the client's arms. Which intervention should the nurse implement first? -
ANSWERSa. Assist the health care provider with intubation.
Rationale:
Ensuring a patent airway is the primary concern. The nurse should assist the health
care provider with intubation, or bag/mask ventilation. Naloxone should reverse the
respiratory depression effects of heroin, but opening the airway is the most critical first
step. There is no data in the question that suggests the client is experiencing ventricular
fibrillation, so the defibrillator is not necessary. Epinephrine will not reverse the
respiratory depression effects of heroin.
The nurse is observing the interaction between a client who delivered her child
yesterday and the newborn. Which behaviors indicate inadequate mother-infant
bonding? (Select all that apply.) - ANSWERSb. The mother states, "My baby does not
seem to like me."
d. The mother comments to the nurse "This baby cries all the time to make me mad."
Rationale:
Maternal comments such as "My baby does not seem to like me" and "The baby cries
all the time to make me mad" indicate inadequate mother-infant bonding. Adequate
bonding behaviors include singing to the baby, use of claiming expressions (the baby's
hands are small like yours) and counting fingers and toes, and stroking the baby's
hands.
The practical nurse (PN) is repositioning a client who has a chest tube. The tubing
becomes stuck on the bed rail, and the chest tube is dislodged from the client's chest.
Which interventions have the highest priority? (Select all that apply.) - ANSWERSc.
Notify the health care provider immediately.
e. Apply an occlusive dressing over the disconnection site.
Rationale:
The priority nursing actions to take when a chest tube is dislodged is to place an
occlusive dressing over the disconnection site and to notify the health care provider
immediately.
The practical nurse (PN) is working with a newly graduated nurse and are caring for a
client with a hip fracture who is in Buck's traction. The PN realizes the newly graduated
nurse understands the purpose of Buck's traction if the orientee makes which
statement? - ANSWERSd. "Buck's traction is intended to immobilize the leg and prevent
muscle spasms."
Rationale:
,Buck's traction is a type of skin traction that may be applied to immobilize the leg and
prevent muscle spasms before surgery.
A client presents to the clinic for the 6-week postpartum checkup. The practical nurse
(PN) suspects that the client may be suffering from postpartum depression. Which
intervention should the PN implement? (Select all that apply.) - ANSWERSb. Determine
availability of the client's support system.
c. Discuss the client's symptoms with the client's health care provider.
d. Encourage the client to discuss her feelings and to ask questions.
e. Monitor the newborn for appropriate growth and development.
Rationale:
The PN's role in assisting a client with postpartum depression includes determining the
availability of family support and other resources as needed, encouraging the client to
verbalize feelings and ask questions, and monitoring the newborn for appropriate
growth and development. In order for the client to receive medications and other
treatments, the PN should discuss the client's symptoms with the health care provider.
The nurse is working with a client who is crying, after the client learns she has uterine
cancer. Which nonverbal action by the nurse best exhibits active listening? -
ANSWERSa. Sit facing the client.
Rationale:
Active listening is conveyed using attentive verbal and nonverbal communication
techniques. To facilitate therapeutic communication and attentiveness, the nurse should
sit facing the client, which lets the client know that the nurse is there to listen. Active
listening skills include postures that are open to the client, such as keeping the arms
open and relaxed, not option B, and leaning toward the client, not option D. To
communicate involvement and willingness to listen to the client, eye contact should be
established and maintained.
A client in the behavioral care unit has been pacing for the last 30 minutes. Which
approach by the practical nurse (PN) is the most therapeutic for this client? -
ANSWERSb. Observing, asking about and acknowledging the client's feelings.
Rationale:
Making an observation and asking about and acknowledging the feelings of the client
are appropriate therapeutic techniques.
The practical nurse (PN) cares for a client who is legally blind. Which intervention
should the PN avoid? - ANSWERSb. Speak loudly so the client knows where the voice
is coming from.
Rationale:
The practical nurse (PN) should use a normal tone of voice when speaking to the client
with limited eyesight.
The practical nurse (PN) is preparing the parents of a newborn diagnosed with a cleft lip
for discharge. Which instruction is most important for the PN to reinforce to the parents?
- ANSWERSb. Suction equipment and bulb syringe should be kept at the bedside.
, Rationale:
Suction equipment and a bulb syringe should be kept at the bedside in case the infant
aspirates.
A client had a transurethral resection of the prostate gland (TURP) 2 days ago, and the
catheter was removed earlier today. The client is voiding urine that is brighter red than
earlier today, and the urine contains several small clots. Which action is the most
appropriate action for the nurse to take? - ANSWERSa. Encourage the client to
increase fluid intake.
Rationale:
A client whose catheter was removed following TURP surgery should be encouraged to
increase fluids and reduce activity to prevent bleeding and to reduce clotting, which
could obstruct the urinary flow. The nurse should encourage fluids prior to contacting
the health care provider. The nurse cannot insert an indwelling catheter without a health
care provider prescription.
When providing the client diagnosed with osteoporosis, a list of foods that should be
part of the client's diet, which items should the practical nurse (PN) include? (Select all
that apply.) - ANSWERSc. Cheese
d. Chicken
e. Tomatoes
Rationale:
The client diagnosed with osteoporosis should eat a diet that is rich in protein, calcium,
vitamins C and D, and iron to prevent further bone loss. Cheese is rich in calcium,
chicken is rich in protein, and tomatoes are rich in vitamin C.
The practical nurse (PN) reviews the chart of a client in labor. The PN notes that the
health care provider (HCP) documented the fetus at +1 station. Where is the fetal
presenting part located? - ANSWERSc. One centimeter below the ischial spine
Rationale:
Fetal presentation is described in stations as they relate to an imaginary line between
the ischial spines. Stations above the line are identified as a negative number and
stations below the line are described as a positive number. Each number is equal to 1
cm. A fetus at +1 station is 1 cm below the ischial spine.
The practical nurse (PN) observes an adolescent client with anorexia nervosa
exercising vigorously. Which is the priority nursing intervention? - ANSWERSb. Interrupt
the client and offer to go for a walk with the client.
Rationale:
Interrupting the client and offering to go for a walk will allow the practical nurse (PN) to
set the pace and offer the client an opportunity to express feelings in a more
constructive way.
Which approach by the practical nurse (PN) is most helpful in communicating with a 2-
year-old child? - ANSWERSb. Talk quietly and assume an eye level position.
Rationale:
with Verified Answers
A client is rushed to the emergency department by friends, who tell the nurse "We think
our friend overdosed on heroin." The client is not breathing. There are fresh needle
marks on the client's arms. Which intervention should the nurse implement first? -
ANSWERSa. Assist the health care provider with intubation.
Rationale:
Ensuring a patent airway is the primary concern. The nurse should assist the health
care provider with intubation, or bag/mask ventilation. Naloxone should reverse the
respiratory depression effects of heroin, but opening the airway is the most critical first
step. There is no data in the question that suggests the client is experiencing ventricular
fibrillation, so the defibrillator is not necessary. Epinephrine will not reverse the
respiratory depression effects of heroin.
The nurse is observing the interaction between a client who delivered her child
yesterday and the newborn. Which behaviors indicate inadequate mother-infant
bonding? (Select all that apply.) - ANSWERSb. The mother states, "My baby does not
seem to like me."
d. The mother comments to the nurse "This baby cries all the time to make me mad."
Rationale:
Maternal comments such as "My baby does not seem to like me" and "The baby cries
all the time to make me mad" indicate inadequate mother-infant bonding. Adequate
bonding behaviors include singing to the baby, use of claiming expressions (the baby's
hands are small like yours) and counting fingers and toes, and stroking the baby's
hands.
The practical nurse (PN) is repositioning a client who has a chest tube. The tubing
becomes stuck on the bed rail, and the chest tube is dislodged from the client's chest.
Which interventions have the highest priority? (Select all that apply.) - ANSWERSc.
Notify the health care provider immediately.
e. Apply an occlusive dressing over the disconnection site.
Rationale:
The priority nursing actions to take when a chest tube is dislodged is to place an
occlusive dressing over the disconnection site and to notify the health care provider
immediately.
The practical nurse (PN) is working with a newly graduated nurse and are caring for a
client with a hip fracture who is in Buck's traction. The PN realizes the newly graduated
nurse understands the purpose of Buck's traction if the orientee makes which
statement? - ANSWERSd. "Buck's traction is intended to immobilize the leg and prevent
muscle spasms."
Rationale:
,Buck's traction is a type of skin traction that may be applied to immobilize the leg and
prevent muscle spasms before surgery.
A client presents to the clinic for the 6-week postpartum checkup. The practical nurse
(PN) suspects that the client may be suffering from postpartum depression. Which
intervention should the PN implement? (Select all that apply.) - ANSWERSb. Determine
availability of the client's support system.
c. Discuss the client's symptoms with the client's health care provider.
d. Encourage the client to discuss her feelings and to ask questions.
e. Monitor the newborn for appropriate growth and development.
Rationale:
The PN's role in assisting a client with postpartum depression includes determining the
availability of family support and other resources as needed, encouraging the client to
verbalize feelings and ask questions, and monitoring the newborn for appropriate
growth and development. In order for the client to receive medications and other
treatments, the PN should discuss the client's symptoms with the health care provider.
The nurse is working with a client who is crying, after the client learns she has uterine
cancer. Which nonverbal action by the nurse best exhibits active listening? -
ANSWERSa. Sit facing the client.
Rationale:
Active listening is conveyed using attentive verbal and nonverbal communication
techniques. To facilitate therapeutic communication and attentiveness, the nurse should
sit facing the client, which lets the client know that the nurse is there to listen. Active
listening skills include postures that are open to the client, such as keeping the arms
open and relaxed, not option B, and leaning toward the client, not option D. To
communicate involvement and willingness to listen to the client, eye contact should be
established and maintained.
A client in the behavioral care unit has been pacing for the last 30 minutes. Which
approach by the practical nurse (PN) is the most therapeutic for this client? -
ANSWERSb. Observing, asking about and acknowledging the client's feelings.
Rationale:
Making an observation and asking about and acknowledging the feelings of the client
are appropriate therapeutic techniques.
The practical nurse (PN) cares for a client who is legally blind. Which intervention
should the PN avoid? - ANSWERSb. Speak loudly so the client knows where the voice
is coming from.
Rationale:
The practical nurse (PN) should use a normal tone of voice when speaking to the client
with limited eyesight.
The practical nurse (PN) is preparing the parents of a newborn diagnosed with a cleft lip
for discharge. Which instruction is most important for the PN to reinforce to the parents?
- ANSWERSb. Suction equipment and bulb syringe should be kept at the bedside.
, Rationale:
Suction equipment and a bulb syringe should be kept at the bedside in case the infant
aspirates.
A client had a transurethral resection of the prostate gland (TURP) 2 days ago, and the
catheter was removed earlier today. The client is voiding urine that is brighter red than
earlier today, and the urine contains several small clots. Which action is the most
appropriate action for the nurse to take? - ANSWERSa. Encourage the client to
increase fluid intake.
Rationale:
A client whose catheter was removed following TURP surgery should be encouraged to
increase fluids and reduce activity to prevent bleeding and to reduce clotting, which
could obstruct the urinary flow. The nurse should encourage fluids prior to contacting
the health care provider. The nurse cannot insert an indwelling catheter without a health
care provider prescription.
When providing the client diagnosed with osteoporosis, a list of foods that should be
part of the client's diet, which items should the practical nurse (PN) include? (Select all
that apply.) - ANSWERSc. Cheese
d. Chicken
e. Tomatoes
Rationale:
The client diagnosed with osteoporosis should eat a diet that is rich in protein, calcium,
vitamins C and D, and iron to prevent further bone loss. Cheese is rich in calcium,
chicken is rich in protein, and tomatoes are rich in vitamin C.
The practical nurse (PN) reviews the chart of a client in labor. The PN notes that the
health care provider (HCP) documented the fetus at +1 station. Where is the fetal
presenting part located? - ANSWERSc. One centimeter below the ischial spine
Rationale:
Fetal presentation is described in stations as they relate to an imaginary line between
the ischial spines. Stations above the line are identified as a negative number and
stations below the line are described as a positive number. Each number is equal to 1
cm. A fetus at +1 station is 1 cm below the ischial spine.
The practical nurse (PN) observes an adolescent client with anorexia nervosa
exercising vigorously. Which is the priority nursing intervention? - ANSWERSb. Interrupt
the client and offer to go for a walk with the client.
Rationale:
Interrupting the client and offering to go for a walk will allow the practical nurse (PN) to
set the pace and offer the client an opportunity to express feelings in a more
constructive way.
Which approach by the practical nurse (PN) is most helpful in communicating with a 2-
year-old child? - ANSWERSb. Talk quietly and assume an eye level position.
Rationale:
