COMPREHENSIVE EXAM B-EVOLVE EXPECTED
QUESTIONS WITH VERIFIED ANSWERS
Question 1.
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube
feedings. Which task performed by the UAP requires immediate intervention by the nurse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees
ANSWER
B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the
client at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C,
and D).
Question 2.
When caring for a postsurgical client who has undergone multiple blood transfusions, which serum
laboratory finding is of most concern to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L
ANSWER
B Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium
level higher than
5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).
Question 3.
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine
ANSWER
A Rationale: The hepatitis B vaccination should be given to all newborns before hospital
discharge (A). HPV is not recommended until adolescence (B). Varicella immunization begins at
12 months (C). Meningo-
,Question 4.
The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed
assistive personnel (UAP)?
A.Assess the need to change a centra line dressing.
B.Obtain a fingerstick blood glucose level.
C.Answer a family member's questions about the client's plan of care.
D.Teach the client side effects to report related to the current medication regimen.
ANSWER
B Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an
appropriate skill for UAP l to perform (B). (A, C, and D) are skills that cannot be delegated to
UAP.
Question 5.
The nurse is caring for a client with an ischemic stroke who has a prescription for tissue
plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select al
that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C.Assess the client for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
ANSWER
B,C,E Rationale: Neurologic assessment, including the NIHSS, is indicated for the client
receiving t-PA. This includes l close monitoring for bleeding during and after the infusion; if
bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C,
and E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A). The
administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a
myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).
Question 6.
When caring for a client in labor, which finding is most important to report to the primary health
care provider?
A.Maternal heart rate, 90 beats/min.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F
ANSWER
B Rationale: A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the
average FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The
others (A, C, and D) are normal findings for a woman in labor.
,Question 7.
The nurse is caring for a client with heart failure who develops respiratory distress and coughs up
pink frothy sputum. Which action should the nurse take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray.
ANSWER
C Rationale: Positioning the patient in a high Fowler's position with dangling feet will decrease
further venous return to the left ventricle (C). The other actions should be performed after the
change in position (A, B, and D).
Question 8.
A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a
shuffling gait, and tremors. Which action by the nurse is most important?A.Administer a dose of
benztropine mesylate (Cogentin) PRN.
ANSWER
A Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
masklike face are extrapyramidal side effects associated with Thorazine. It is most important
for the nurse to administer an anticholinergic such as Cogentin to
Question 9.
A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to
continue fur ther assessment of the infant?
A.Two-month-old who is unable to rol from back to abdomen
B.Ten-month-old who cannot sit with out support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words
ANSWER
B Rationale:
- As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone
of l rolling over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is
common from 7 to
- 9 months (C). Speaking a few words is expected at about 12 months (D).
, Question 10.
Which intervention should be included in the plan of care for a client admitted to the hospital with
ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
ANSWER
C Rationale: A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical
manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could worsen the
condition.
Question 11.
The nurse is caring for a client with deep vein thrombosis who is on a con tinuous IV heparin
infusion. The acti-
ANSWER
D
- Rationale: An aPTT more than 100 seconds is a critical-
Question 12.
While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the
client's health care provider is on the telephone. What ac tion should the nurse instruct the uni
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain rea son for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit.
ANSWER
C Rationale: Another nurse should be asked to take the phone
- call (C), which allows the nurse to stay at the bed- t side to complete the assessment of the
client's chest pain. (A and B) should not be done during an acute change in the client's
condition. Requesting the health care provider (D) to come to the unit is
- premature until the nurse completes assessment of the client's status.
QUESTIONS WITH VERIFIED ANSWERS
Question 1.
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube
feedings. Which task performed by the UAP requires immediate intervention by the nurse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees
ANSWER
B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the
client at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C,
and D).
Question 2.
When caring for a postsurgical client who has undergone multiple blood transfusions, which serum
laboratory finding is of most concern to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L
ANSWER
B Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium
level higher than
5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).
Question 3.
Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine
ANSWER
A Rationale: The hepatitis B vaccination should be given to all newborns before hospital
discharge (A). HPV is not recommended until adolescence (B). Varicella immunization begins at
12 months (C). Meningo-
,Question 4.
The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed
assistive personnel (UAP)?
A.Assess the need to change a centra line dressing.
B.Obtain a fingerstick blood glucose level.
C.Answer a family member's questions about the client's plan of care.
D.Teach the client side effects to report related to the current medication regimen.
ANSWER
B Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an
appropriate skill for UAP l to perform (B). (A, C, and D) are skills that cannot be delegated to
UAP.
Question 5.
The nurse is caring for a client with an ischemic stroke who has a prescription for tissue
plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select al
that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C.Assess the client for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
ANSWER
B,C,E Rationale: Neurologic assessment, including the NIHSS, is indicated for the client
receiving t-PA. This includes l close monitoring for bleeding during and after the infusion; if
bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C,
and E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A). The
administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a
myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).
Question 6.
When caring for a client in labor, which finding is most important to report to the primary health
care provider?
A.Maternal heart rate, 90 beats/min.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F
ANSWER
B Rationale: A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the
average FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The
others (A, C, and D) are normal findings for a woman in labor.
,Question 7.
The nurse is caring for a client with heart failure who develops respiratory distress and coughs up
pink frothy sputum. Which action should the nurse take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray.
ANSWER
C Rationale: Positioning the patient in a high Fowler's position with dangling feet will decrease
further venous return to the left ventricle (C). The other actions should be performed after the
change in position (A, B, and D).
Question 8.
A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a
shuffling gait, and tremors. Which action by the nurse is most important?A.Administer a dose of
benztropine mesylate (Cogentin) PRN.
ANSWER
A Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and
masklike face are extrapyramidal side effects associated with Thorazine. It is most important
for the nurse to administer an anticholinergic such as Cogentin to
Question 9.
A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to
continue fur ther assessment of the infant?
A.Two-month-old who is unable to rol from back to abdomen
B.Ten-month-old who cannot sit with out support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words
ANSWER
B Rationale:
- As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone
of l rolling over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is
common from 7 to
- 9 months (C). Speaking a few words is expected at about 12 months (D).
, Question 10.
Which intervention should be included in the plan of care for a client admitted to the hospital with
ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal.
ANSWER
C Rationale: A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical
manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could worsen the
condition.
Question 11.
The nurse is caring for a client with deep vein thrombosis who is on a con tinuous IV heparin
infusion. The acti-
ANSWER
D
- Rationale: An aPTT more than 100 seconds is a critical-
Question 12.
While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the
client's health care provider is on the telephone. What ac tion should the nurse instruct the uni
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain rea son for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit.
ANSWER
C Rationale: Another nurse should be asked to take the phone
- call (C), which allows the nurse to stay at the bed- t side to complete the assessment of the
client's chest pain. (A and B) should not be done during an acute change in the client's
condition. Requesting the health care provider (D) to come to the unit is
- premature until the nurse completes assessment of the client's status.
