Comp predictor B Exam 2022/2023 Questions and Answers

A nurse is preparing to replace a patient's transdermal fentanyl patch after 72 hours of use. After opening the packet with the new pouch, the patient refuses to accept it. Which action should the nurse take? A) Withhold pain medications for 24 hr after the old patch is removed. B) Ask another nurse to witness the disposal of the new patch. C) Seal the patches in a plastic bag and place in the client's trash basket. D) Stick the two patches to each other and place them in the sharps bin. - ANSWER B) Ask another nurse to witness the disposal of the new patch. A nurse is caring for a client with a PE. The client is receiving heparin IV at 1,200 units/hr and warfarin 5 mg PO daily. The morning lab values are aPTT 98 seconds and INR 1.8. Which action should the nurse take? A) Prepare to administer vitamin K1. B) Prepare to administer alteplase. C) Withhold the heparin infusion. D) Withhold the next dose of warfarin. - ANSWER C) Withhold the heparin infusion. The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage should be reduced or the infusion withheld until the aPTT returns to the therapeutic range. A nurse at an urgent care clinic is assessing a patient with impaired vision in 1 eye. Which report from the patient should indicate to the nurse that the client has a detached retina? A) Halos around lights B) Floating dark spots C) Pain in the affected eye D) Cloudy vision - ANSWER B) Floating dark spots A nurse is assessing an infant with hydrocephalus and is 6 hours post-op following placement of a VP shunt. Which finding should the nurse report to the provider? A) Heart rate 122/min B) Irritability when being held C) Hypoactive bowel sounds D) Urine specific gravity 1.018 - ANSWER B) Irritability when being held A nurse is assessing a newborn's HR. Which action should the nurse take? A) Assess the apical pulse while the newborn is crying to detect cardiac problems. B) Palpate the radial pulse and determine the rate based on number of beats per minute. C) Listen to the apical pulse while palpating the radial pulse to detect variance. D) Auscultate the apical pulse and count beats for at least 1 min. - ANSWER D) Auscultate the apical pulse and count beats for at least 1 min. A nurse is caring for a client with a fecal impaction. Which action should the nurse take when digitally evacuating the stool? A) Place the client in the lithotomy position. B) Elicit a vagal response by performing gentle rectal stimulation. C) Administer oral bisacodyl 30 min prior to the procedure. D) Insert a lubricated gloved finger and advance along the rectal wall. - ANSWER D) Insert a lubricated gloved finger and advance along the rectal wall. A nurse is providing dietary teaching to a patient taking phenelzine. Which food recommendations should the nurse make? (Select all) A) Broccoli B) Yogurt C) Pepperoni pizza D) Cream cheese E) Bologna sandwich - ANSWER A) Broccoli B) Yogurt D) Cream cheese A nurse administers an incorrect dose of a med to a client. The nurse recognizes the error immediately and completes an incident report. Which fact related to the incident should the nurse document in the client's medical record? A) Completion of the incident report B) Time the medication was given C) Reason for the medication error D) Notification of the pharmacist - ANSWER B) Time the medication was given A nurse on a pediatric unit received report on 4 children. Which child should the nurse assess first? A) A 6-month-old infant who has croup and an O2 saturation of 92% on room air B) A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication C) A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain - ANSWER D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain Using the urgent vs. non-urgent approach to client care, the nurse should determine that the client to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this can be an indication of peritonitis from a ruptured appendix. A community health nurse is providing teaching about home safety with a group of elderly clients. Which statement should the nurse make? A) "Unplug your appliances by grasping the cord and pulling it straight from the outlet." B) "Set your water heater temperature at 130 degrees Fahrenheit." C) "Use throw rugs in high-traffic areas to partially cover wood floors." D) "Have grab bars installed around your bathtub and toilet." - ANSWER D) "Have grab bars installed around your bathtub and toilet." A nurse in the ED is assessing a school-age child who was brought in by her parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which action should the nurse take? A) Discuss his suspicion of physical abuse with the provider. B) Confront the parents with his suspicion of physical abuse. C) Ask the hospital security to detain and question the parents. D) Contact child protective services. - ANSWER D) Contact child protective services. A nurse is caring for a patient with acute blood loss following a trauma. The patient refuses a blood transfusion that could save his life. Which action should the nurse take first? A) Document the client's refusal in the medical record. B) Honor the client's decision to refuse the blood transfusion. C) Explore the client's reasons for refusing the treatment. D) Discuss the client's refusal with the provider. - ANSWER C) Explore the client's reasons for refusing the treatment. A nurse is teaching a client at 20 weeks gestation about common prenatal discomfort. Which statement by the client indicates an understanding of the teaching? A) "I will decrease my intake of high-fiber foods." B) "I will apply an anti-inflammatory ointment if I develop a rash on my face." C) "I will sleep flat on my back if I develop back pain." D) "I will wear a supportive bra overnight." - ANSWER D) "I will wear a supportive bra overnight." A nurse is providing discharge education to a patient who is to receive home oxygen therapy. Which instruction should the nurse include in the teaching? A) Check the functioning of oxygen equipment once each week. B) Wear clothing made with cotton fabrics while oxygen is in use. C) Apply petroleum-based lubricant to the nares as needed. D) Store full oxygen tanks on their side. - ANSWER B) Wear clothing made with cotton fabrics while oxygen is in use. The nurse should teach the client to apply a water-soluble lubricant to soothe irritation of the mucous membranes, because products containing oils are flammable when near oxygen. A nurse manager is preparing an education session about advocacy to a group of nurses. The nurse manager should include what information in the teaching? A) Advocacy is a leadership role that helps others to self-actualize. B) Subordinates are an advocate for the nurse manager. C) Advocacy is to encourage client dependence in decision making. D) Nurse managers should distrust people who speak out about harmful or inappropriate professional practices. - ANSWER A) Advocacy is a leadership role that helps others to self-actualize. A nurse is caring for a patient receiving continuous bladder irrigation following a transurethral resection of the prostate. The patient reports bladder spasms and the nurse observes a decreased urinary output. Which action should the nurse take? A) Increase tension on the urinary catheter. B) Irrigate the catheter with 0.9% sodium chloride irrigation. C) Assist the client to ambulate. D) Remove the urinary catheter immediately. - ANSWER B) Irrigate the catheter with 0.9% sodium chloride irrigation. Decreased urine output and bladder spasms indicate internal obstructions of the catheter. Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify the provider if the obstruction does not clear. A nurse is caring for a child with sickle cell anemia and is having a vaso-occlusive crisis. Which intervention should the nurse implement first? A) Collect a blood sample for laboratory tests. B) Administer medication for pain. C) Apply warm packs to affected areas. D) Infuse IV fluids. - ANSWER D) Infuse IV fluids. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to infuse IV fluids to promote hydration and circulation. Increased fluid reduces the tissue and organ ischemia caused by the clumping of the RBCs. A nurse is providing patient education about the basal body temperature method of birth control. What information should the nurse include in the teaching? A) "Your body temperature will drop approximately 1 degree 1 week after ovulation." B) "You should take your body temperature each evening prior to going to sleep." C) "Your body temperature might decrease slightly just prior to ovulation." D) "Your body temperature is at its highest during menstruation." - ANSWER C) "Your body temperature might decrease slightly just prior to ovulation." The nurse should teach the client that a drop in body temperature of approximately 0.25° C (0.5° F) commonly occurs immediately prior to ovulation. A nurse in the ED is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which action should the nurse take? A) Contact the facility's ethics committee. B) Obtain consent from the client's employer. C) Limit care to comfort measures. D) Proceed with provision of medical care. - ANSWER D) Proceed with provision of medical care. A nurse is caring for a client who has fluid volume overload. Which task should the nurse delegate to the AP? A) Palpate the degree of edema. B) Regulate IV pump fluid rate. C) Measure the client's daily weight. D) Assess the client's vital signs. - ANSWER C) Measure the client's daily weight. A nurse is assessing a patient with hypocalcemia. Which site should the nurse tap to elicit a positive Chvostek's sign? A) between the eyebrows B) under the eye C) cheek D) chin - ANSWER C) cheek A nurse is reviewing the urinalysis report of a client with acute glomerulonephritis. Which finding should the nurse expect in the client's urine? A) Uric acid crystals B) Protein C) WBCs D) Nitrates - ANSWER B) Protein Increased glomerular permeability allows protein to filter into the urine. Therefore, this is an expected finding in a client who has glomerulonephritis. A nurse is creating a plan for care of a newly admitted child. Which action should the nurse include in the plan? (Click exhibit) A) Initiate droplet isolation precautions. B) Keep the child on NPO status for 12 hr. C) Maintain the child on bed rest for 24 hr. D) Administer high dose antibiotic therapy. - ANSWER D) Administer high dose antibiotic therapy. The nurse should include administering high-dose antibiotic therapy in the child's plan of care. Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections such as Burkholderia cepacia. A nurse is caring for a client with cancer and is deciding between 2 treatment options. The client asks the nurse for assistance with the decision. Which response should the nurse make? A) "It's been difficult for everyone who has ever had to make this decision." B) "Tell me more about your understanding of the options." C) "I'm sure you will make the right choice." D) "I will contact your provider to have him talk with you further." - ANSWER B) "Tell me more about your understanding of the options." A nurse is caring for a patient receiving hemodialysis with an AV fistula in the right arm. Which intervention should the nurse include in the patient's plan of care? A) Avoid elevating the affected extremity. B) Auscultate the affected extremity for a bruit. C) Discourage range-of-motion exercises in the affected extremity. D) Perform venipuncture in the affected extremity. - ANSWER B) Auscultate the affected extremity for a bruit. A nurse in the oncology unit is administering doxorubicin to a client with breast cancer. Which action should the nurse take? A) Hold the dose if the client's bilirubin level is 2.0 mg/dL. B) Inject the solution slowly over 2 min. C) Administer an antiemetic to the client 15 min prior to the medication. D) Inspect the client's mucosa for petechiae every 8 hr. - ANSWER D) Inspect the client's mucosa for petechiae every 8 hr. The nurse should inspect the client's mucosa for petechiae every 8 hr because this medication causes thrombocytopenia and increases the risk of bleeding. The nurse should also assess the client for hematuria, guaiac, and bruising. A hospice nurse is consulting with a patient and her family about receiving home services. Which statement should the nurse identify as an indication that the family understands home hospice care? A) "We can expect the hospice nurse to provide support for us after our mother's death." B) "A hospice nurse will come to the house each time our mother needs pain medication." C) "Now that my mother is receiving hospice services, we will not be able to get respite care." D) "Hospice care focuses on arranging treatment that will prolong our mother's life." - ANSWER A) "We can expect the hospice nurse to provide support for us after our mother's death." A nurse is caring for a patient with major depressive disorder and has signed an informed consent to receive ECT. The patient states "I'm not sure about this now. I'm afraid it's too risky." What response should the nurse make? A) "Perhaps you think the ECT is dangerous, but I can guarantee it's quite safe." B) "You have the right to refuse to have the ECT, even after you have agreed to it." C) "Everyone gets a little nervous about this procedure as the time for it approaches." D) "Your doctor wouldn't have suggested this procedure if he didn't think it would help you." - ANSWER B) "You have the right to refuse to have the ECT, even after you have agreed to it." A nurse is providing discharge instructions about newborn care to a client 2 days postpartum. Which statements indicate understanding of the teaching? (Select all) A) "I will breastfeed my baby on a schedule of every 4 hours." B) "I will bathe my baby daily." C) "I will be place my baby on her stomach for sleeping." D) "I will cover my baby's body when I wash her hair." E) "I will use the bulb syringe first in her mouth and then in her nose." - ANSWER D) "I will cover my baby's body when I wash her hair." E) "I will use the bulb syringe first in her mouth and then in her nose." A nurse is assigning task roles for a group of patients in a community mental health clinic. Which task should the nurse assign to the mother of the group functioning as the orienter? A) Measuring the group's work against the assigned objectives B) Noting the progress of the group toward assigned goals C) Sharing experiences as an authority figure D) Offering new and fresh ideas on an issue - ANSWER B) Noting the progress of the group toward assigned goals A nurse must recommend clients for discharge to make room for several critically injured clients from a local disaster. Which client should the nurse recommend for discharge? A) A client who has cellulitis and is receiving oral antibiotics every 8 hr B) A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex C) A mother and her newborn 12 hr postdelivery D) A client who has lower extremity weakness and is newly admitted for observation - ANSWER A) A client who has cellulitis and is receiving oral antibiotics every 8 hr A nurse is developing a client education program about osteoporosis for older adult clients. What variable is a risk factor for osteoporosis? A) Obesity B) Acromegaly C) Estrogen replacement therapy D) Sedentary lifestyle - ANSWER D) Sedentary lifestyle A charge nurse is providing an educational session about infection control for a group of staff nurses. Which statement by a staff nurse indicates understanding of isolation precautions? A) "Droplet precautions should be initiated for a client who tests positive for measles." B) "A client who requires airborne precautions should be placed in a negative-pressure airflow room." C) "Airborne precautions should be initiated for a client who has Clostridium difficile." D) "A clients who is immunocompromised should be placed in a negative-pressure airflow room." - ANSWER B) "A client who requires airborne precautions should be placed in a negative-pressure airflow room." The nurse should initiate airborne precautions, rather than droplet precautions, for a client who has measles. A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. What action should the nurse plan to perform? A) Administer a bowel preparation the night before the procedure. B) Place the client on bed rest for 24 hr after the procedure. C) Perform pulmonary function tests following the procedure. D) Instruct the client to avoid deep breathing during the procedure. - ANSWER D) Instruct the client to avoid deep breathing during the procedure. It is important for the nurse to remind the client to avoid deep breathing during a thoracentesis to avoid puncturing the pleura. A nurse is caring for a school-age child taking valproic acid. The nurse should expect the provider to order which diagnostic test? A) Chest x-ray B) Serum liver enzyme levels C) ABGs D) Urine culture and sensitivity - ANSWER B) Serum liver enzyme levels Valproic acid can cause hepatic toxicity. Therefore, the nurse should expect the provider to prescribe laboratory tests to assess the child's liver function. A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which observation should the nurse identify as an indicator for potential violence? A) The client is taking numerous deep, measured breaths. B) The client is calmly telling his partner that "the staff here is so controlling." C) The client is sitting with his head in his hands and appears to be crying. D) The client is pacing around the chair in which his partner is sitting. - ANSWER D) The client is pacing around the chair in which his partner is sitting. Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the client by speaking to him in a low, calm voice using short sentences. A home health nurse is evaluating a school-age child with cystic fibrosis. The nurse should indicate a request for a high-frequency chest compression vest in response to which parent statement? A) "My child doesn't like to sit still for nebulizer treatments." B) "I think that my child has been running a fever over the last couple of days." C) "My child has only a small amount of mucus after percussion therapy." D) "I am concerned about my child's future participation in team sports." - ANSWER C) "My child has only a small amount of mucus after percussion therapy." A nurse is creating a plan of care for a patient with left-sided weakness following a stroke. Which intervention should the nurse include in the plan? A) Massage bony prominences on the client's left side. B) Support the client's left arm on a pillow while sitting. C) Position the bedside table on the client's left side. D) Place the client's cane on his left side while ambulating. - ANSWER B) Support the client's left arm on a pillow while sitting. A nurse on an impatient unit is caring for a client with schizophrenia and recently started taking risperidone. Which action should the nurse take? A) Implement fall precautions for the client. B) Monitor the client's thyroid function. C) Place the client on a fluid restriction. D) Discontinue the medication if hallucinations occur. - ANSWER A) Implement fall precautions for the client. Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. Therefore, the nurse should initiate fall precautions for the client. A nurse in the ED is caring for a child with a fever and fluid-filled vesicles on the trunk and extremities. Which intervention should the nurse identify as priority? A) Encourage oral fluids. B) Apply topical calamine lotion. C) Administer acetaminophen as an antipyretic. D) Initiate transmission-based precautions. - ANSWER D) Initiate transmission-based precautions. These findings indicate this child most likely has varicella, which is an infectious disease. Therefore, the first action the nurse should take is to initiate transmission-based precautions. A nurse is assessing a client for compartment syndrome. Which finding should the nurse expect? A) Fever B) Shortened femoral neck C) Edema D) Dark brown urine - ANSWER C) Edema A nurse has received report on 4 patients. Which should the nurse assess first? A) A client who is postoperative with abdominal distention and no bowel sounds B) A client who has diabetes mellitus and a blood glucose level of 105 mg/dL C) A client who has heart failure and 2+ pitting edema D) A client who is receiving maintenance IV fluids and needs a new IV catheter - ANSWER A) A client who is postoperative with abdominal distention and no bowel sounds A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which finding should the nurse identify as an adverse effect of this medication? A) Hypotension B) Report of tinnitus C) Report of chest pain D) Ecchymosis - ANSWER C) Report of chest pain The nurse should recognize that a report of chest pain by the client can indicate an adverse effect of the medication. Epinephrine increases cardiac workload and oxygen demand, which can result in angina. A nurse is providing teaching to a patient 24 weeks gestation and is scheduled for a 3 hour oral glucose tolerance test. Which instruction should the nurse include in the teaching? A) "Limit your fat intake for 72 hours before the test." B) "You will need to fast the night before the test." C) "We will collect a urine sample on the morning of the test." D) "A blood sample will be collected every 30 minutes during the test." - ANSWER B) "You will need to fast the night before the test." A nurse is assessing an older adult client with pneumonia. Which finding should the nurse expect? A) Paradoxic chest movement B) Subcutaneous emphysema C) Acute confusion D) Distended neck veins - ANSWER C) Acute confusion An older adult client who has pneumonia will also typically have acute confusion, fatigue, lethargy, and anorexia. A nurse is providing teaching for a client about his right to confidentiality. Which statement should the nurse make? A) "You can provide a list of family members who can receive information about your diagnosis." B) "Your provider can legally discuss your test results with your partner without your permission." C) "Your provider will need to approve your advance directives before we can implement them." D) "You can give your friend who is an RN in another department permission to access your medical records." - ANSWER A) "You can provide a list of family members who can receive information about your diagnosis." A nurse in the ED is caring for a patient with nausea and vomiting for 2 days. Which finding should the nurse expect? A) Hgb 15.0 g/dL B) Urine specific gravity 1.052 C) Urine osmolality 300 mOsm/L water D) Hct 44% - ANSWER B) Urine specific gravity 1.052 The nurse should recognize this urine specific gravity is significantly elevated, indicating dehydration from vomiting. A nurse is caring for a post-op patient after receiving moderate (conscious) sedation. The patient suddenly becomes restless and reports feeling lightheaded. Which action should the nurse take? A) Check the client's temperature. B) Prepare to administer acetylcysteine to the client. C) Place the client in the Trendelenburg position. D) Check the client's oxygen saturation level. - ANSWER D) Check the client's oxygen saturation level. A nurse is assessing a client at 11 weeks gestation and reports drinking ginger tea. Which finding indicates the client's use of ginger tea is effective? A) The client reports a decrease in episodes of nausea. B) The client reports a decrease in breast tenderness. C) The client reports a decrease in headaches. D) The client reports a decrease in urinary frequency. - ANSWER A) The client reports a decrease in episodes of nausea. A nurse is providing teaching to a patient with a new diagnosis of type 1 DM. The nurse should instruct the client to monitor which finding as a manifestation of hypoglycemia? A) Irritability B) Increased urination C) Vomiting D) Facial flushing - ANSWER A) Irritability A nurse is caring for a client who has a DVT. Which action should the nurse take? A) Teach the client to massage the affected extremity. B) Instruct the client to elevate the affected extremity when sitting. C) Assess pulses proximal to the affected area. D) Apply a cold compress to the affected extremity. - ANSWER B) Instruct the client to elevate the affected extremity when sitting. A nurse is providing information to a client immediately before his scheduled Romberg test. Which statement should the nurse make? A) "You will be standing with your feet 1 foot apart." B) "You will place and hold your hands on your hips." C) "I will be standing across the room from you to evaluate your sense of balance." D) "I will be checking you once with your eyes open and once with them closed." - ANSWER D) "I will be checking you once with your eyes open and once with them closed." A nurse is providing teaching to the parents of a child who has autism spectrum disorder. Which instruction should the nurse include? A) Maintain a flexible daily schedule for the child. B) Use a reward system to modify the child's behavior. C) Provide a variety of family members to care for the child. D) Administer alprazolam as needed to reduce the child's anxiety. - ANSWER B) Use a reward system to modify the child's behavior. A nurse is providing teaching to a client who is to undergo ECT. The nurse should inform the client that which finding is an adverse effect of ECT? A) Agitation B) Short-term memory loss C) Post-treatment seizures D) Incontinence of the bowel and bladder - ANSWER B) Short-term memory loss A nurse is caring for a client who has TB. Which action should the nurse plan to take to prevent the transmission of the disease? A) Initiate contact precautions for the client. B) Restrict visitors from entering the client's room. C) Wear a surgical mask during contact with the client. D) Have the client wear a surgical mask while being transported outside the room. - ANSWER D) Have the client wear a surgical mask while being transported outside the room. A nurse in a peds clinic is assessing the reflexes of an infant who is 1 week old. Which image demonstrates correct procedure to elicit the palmar grasp reflex? - ANSWER The nurse should elicit the palmar reflex by touching the palms of the infant's hands near the base of the digits, causing flexion of the fingers. A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which component of the MSE is priority for the nurse to assess? A) Mood B) Speech C) Ideas of self-harm D) Perceptual disturbances - ANSWER C) Ideas of self-harm A nurse is caring for a client who is taking chlorpromazine. Which finding should the nurse identify as an indication that the med is effective? A) Decreased blood pressure B) Decreased hallucinations C) Decreased cholesterol D) Decreased esophageal reflux - ANSWER B) Decreased hallucinations A nurse is assessing a client whose partner recently died. The client states "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make? A) "It's natural for you to feel this way now, but things will get better with time." B) "You seem to be having a difficult time right now." C) "Why do you feel like your life isn't worth living?" D) "You'd be surprised how many people experience these feelings." - ANSWER B) "You seem to be having a difficult time right now." A nurse is developing a discharge plan for a school-age child with thrombocytopenia. The nurse should instruct the child to avoid what? A) Large groups of people B) Quickly changing positions C) Eating fresh fruits D) Blowing the nose - ANSWER D) Blowing the nose The nurse should instruct the child who has thrombocytopenia to avoid blowing the nose because it increases the risk for bleeding or hemorrhaging. A nurse is reviewing the lab report of a client who has end-stage kidney disease and received hemodialysis 24 hours ago. Which of the following lab values should the nurse report to the provider? A) Platelets 268,000/mm3 B) Calcium 9.2 mg/dL C) WBC 5,200/mm3 D) Sodium 148 mEq/L - ANSWER D) Sodium 148 mEq/L A nurse is caring for a client with a magnesium level of 2.5. Which intervention should the nurse plan to take? A) Initiate continuous cardiac monitoring.