NUR283 Comp Exam Revised(2025)
The nurse is caring for a 3-year-old who has had 160ml of urine output over the past 8-hour period. The child weighs
33 pounds. Which of the following actions should the nurse take?
Correct Answer: D- Continue to monitor
Rationale – this is an expected finding -?? (look up in Saunders how to do math for urine output for child)
***
The nurse is caring for a client who had abdominal surgery and has developed an evisceration. After calling for
assistance, which of the following actions would the nurse take next?
Correct Answer: B. Use a moist ABD to cover the abdomen
Rationale – Call, cover, splint – Client should be placed in a semi fowlers position, this reduces pressure on the
abdominal wall. Moist dressing prevents drying of the organs.
***
The nurse is caring for a client that develops the following cardiac rhythm –
Correct Answer: A - PVC - check potassium
The nurse working in the PACU is assessing the client who had a below the knee amputation. The nurse should give
priority to assess the client for?
Correct Answer: A. Hypovolemic shock - possible bleeding
***
The nurse is assessing the client who has a suspected retinal detachment of the left eye. Which of the following client
statements would be consistent with this diagnosis?
Correct Answer: A. I see floating dark spots in my left eye
***
The nurse is assessing a client who has developed an Addisonian crisis. Which of the following findings is consistent
with this diagnosis?
Correct Answer: A - a blood glucose of less than 60
The nurse is caring for a client who had lumbar spinal surgery 8 hours ago. It would be a priority for the nurse to
notify the surgeon if
Correct Answer: C. Has a moderate amount of clear drainage on the surgical dressing
***
Medications should be given through what?
Correct Answer: Central line
The nurse working on a medical surgical unit is delegating tasks to unlicensed personnel. Which of the following
delegated tasks would REQUIRE FOLLOW UP by the charge nurse?
Correct Answer: A. Assisting a client who had a paracentect 2 hours ago to get out of bed for the first time.
Rationale – anytime a client is doing something for the first time the RN needs to do it
, The nurse is prioritizing patient care after a change of shift report. The nurse should first plan to see the patient who:
Correct Answer: B. Had an endoscopic retrograde cholangiopancreatography 30 minutes ago and is reporting
difficulty swallowing Rationale – Difficulty swallowing – ABC’s!
The nurse working on the mom/baby unit has become aware of the following client situations. Which of the following
clients should the nurse INITIALLY assess?
Correct Answer: C. a neonate who is 4 hours old, whose resting HR is 95 BPM.
Rationale – Normal HR for a newborn is 120-140 BPM – 95 is a LOW BPM
A nurse working on a medical surgical unit has just received a handoff report on the following clients. The nurse
should FIRST plan to assess the client who has:
Correct Answer: D. Acute pancreatitis and is reporting the development of pain on deep inspiration
Rationale – “acute” if not caught early, will possible burst and patient will become septic
The nurse working on a pediatric unit is caring for the following children who have been admitted in the past 12 hours.
It would be a priority goal for the nurse to initiate an interdisciplinary conference for the child who:
Correct Answer: A. 5 yr old with diagnosed cystic fibrosis at birth and has been hospitalized 4 times in the past 2
months
Rationale – This is conferencing everyone!!! PT, dietary, spiritual guidance, everyone should be conferenced for this
patient. This question is asking – WHO / WHICH child is requiring the MOST help and resources???
The nurse working in the ED has received the following prescriptions for a newly admitted client. Which prescriptions
should the nurse implement FIRST?
Correct Answer: D. Initiate IV sodium and potassium for a client admitted with diarrhea and dehydration who has a
serum potassium level of 2.9.
Rationale – serum potassium of 2.9 is CRITICAL -this is a critical lab value and should be addressed first!
A nurse working in a community health clinic is assessing clients who are waiting to be seen. Which client should the
nurse have the primary health care provider see FIRST?
Correct Answer: A. a 57 year old with graves disease with a temperature of 100.5
Rationale – Thyroid issue
A nurse working on a pediatric cardiac unit is reviewing the telemetry monitors for assigned clients. Which client
should the nurse INITIALLY plan to assess?
Correct Answer: A. 2 year old toddler who is walking in the hallway and has a HR of 160 BPM
Rationale – Abnormal HR – all the other choices were normal for the child
A nurse is caring for a male client who has a deep partial thickness and a full thickness burn to 45 % of the lower
body. It would be a PRIORITY for the nurse to notify the primary health care physician if the client has:
Correct Answer: D. A urinary output of 45 ml over the past two hours
Rationale – Normal urinary output per hour is 30 ml.hr. This question really has nothing to do with “burn” and more to
know your normal values.
The nurse is caring for a 3-year-old who has had 160ml of urine output over the past 8-hour period. The child weighs
33 pounds. Which of the following actions should the nurse take?
Correct Answer: D- Continue to monitor
Rationale – this is an expected finding -?? (look up in Saunders how to do math for urine output for child)
***
The nurse is caring for a client who had abdominal surgery and has developed an evisceration. After calling for
assistance, which of the following actions would the nurse take next?
Correct Answer: B. Use a moist ABD to cover the abdomen
Rationale – Call, cover, splint – Client should be placed in a semi fowlers position, this reduces pressure on the
abdominal wall. Moist dressing prevents drying of the organs.
***
The nurse is caring for a client that develops the following cardiac rhythm –
Correct Answer: A - PVC - check potassium
The nurse working in the PACU is assessing the client who had a below the knee amputation. The nurse should give
priority to assess the client for?
Correct Answer: A. Hypovolemic shock - possible bleeding
***
The nurse is assessing the client who has a suspected retinal detachment of the left eye. Which of the following client
statements would be consistent with this diagnosis?
Correct Answer: A. I see floating dark spots in my left eye
***
The nurse is assessing a client who has developed an Addisonian crisis. Which of the following findings is consistent
with this diagnosis?
Correct Answer: A - a blood glucose of less than 60
The nurse is caring for a client who had lumbar spinal surgery 8 hours ago. It would be a priority for the nurse to
notify the surgeon if
Correct Answer: C. Has a moderate amount of clear drainage on the surgical dressing
***
Medications should be given through what?
Correct Answer: Central line
The nurse working on a medical surgical unit is delegating tasks to unlicensed personnel. Which of the following
delegated tasks would REQUIRE FOLLOW UP by the charge nurse?
Correct Answer: A. Assisting a client who had a paracentect 2 hours ago to get out of bed for the first time.
Rationale – anytime a client is doing something for the first time the RN needs to do it
, The nurse is prioritizing patient care after a change of shift report. The nurse should first plan to see the patient who:
Correct Answer: B. Had an endoscopic retrograde cholangiopancreatography 30 minutes ago and is reporting
difficulty swallowing Rationale – Difficulty swallowing – ABC’s!
The nurse working on the mom/baby unit has become aware of the following client situations. Which of the following
clients should the nurse INITIALLY assess?
Correct Answer: C. a neonate who is 4 hours old, whose resting HR is 95 BPM.
Rationale – Normal HR for a newborn is 120-140 BPM – 95 is a LOW BPM
A nurse working on a medical surgical unit has just received a handoff report on the following clients. The nurse
should FIRST plan to assess the client who has:
Correct Answer: D. Acute pancreatitis and is reporting the development of pain on deep inspiration
Rationale – “acute” if not caught early, will possible burst and patient will become septic
The nurse working on a pediatric unit is caring for the following children who have been admitted in the past 12 hours.
It would be a priority goal for the nurse to initiate an interdisciplinary conference for the child who:
Correct Answer: A. 5 yr old with diagnosed cystic fibrosis at birth and has been hospitalized 4 times in the past 2
months
Rationale – This is conferencing everyone!!! PT, dietary, spiritual guidance, everyone should be conferenced for this
patient. This question is asking – WHO / WHICH child is requiring the MOST help and resources???
The nurse working in the ED has received the following prescriptions for a newly admitted client. Which prescriptions
should the nurse implement FIRST?
Correct Answer: D. Initiate IV sodium and potassium for a client admitted with diarrhea and dehydration who has a
serum potassium level of 2.9.
Rationale – serum potassium of 2.9 is CRITICAL -this is a critical lab value and should be addressed first!
A nurse working in a community health clinic is assessing clients who are waiting to be seen. Which client should the
nurse have the primary health care provider see FIRST?
Correct Answer: A. a 57 year old with graves disease with a temperature of 100.5
Rationale – Thyroid issue
A nurse working on a pediatric cardiac unit is reviewing the telemetry monitors for assigned clients. Which client
should the nurse INITIALLY plan to assess?
Correct Answer: A. 2 year old toddler who is walking in the hallway and has a HR of 160 BPM
Rationale – Abnormal HR – all the other choices were normal for the child
A nurse is caring for a male client who has a deep partial thickness and a full thickness burn to 45 % of the lower
body. It would be a PRIORITY for the nurse to notify the primary health care physician if the client has:
Correct Answer: D. A urinary output of 45 ml over the past two hours
Rationale – Normal urinary output per hour is 30 ml.hr. This question really has nothing to do with “burn” and more to
know your normal values.
