COMPREHENSIVE EXAM #3
QUESTIONS WITH CORRECT ANSWERS
A 38-year-old female client is admitted to the mental health unit after a recent manic
episode of spending large amounts of money on new furniture, making excessive long-
distance phone calls, and not sleeping for three days. During the admission process,
the client is wearing a green bathing suit. What intervention should the nurse
implement? - Answer-Assess the client's needs for food, liquids, and rest.
During a group therapy session, a client with hypomania threatens to strike another
client. What intervention is best for the nurse to implement? - Answer-Firmly inform the
client that acting out anger is not acceptable.
A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and
multiple food allergies is scheduled for surgery. Which action should the nurse
implement? - Answer-Document a possible Type I latex allergy.
In reviewing the medical record, the nurse notes that a client's last eye examination
revealed an IOP of 28 mmHg. What information should the nurse ask the client? -
Answer-Use of prescribed eye drops since last exam by ophthalmologist.
Which action should the nurse implement to assess for JVD in a client with HF? -
Answer-Observe the vertical distention of the veins as the client is gradually elevated to
an upright position.
The nurse identifies a client's laboratory results and identifies an elevated serum
ammonia level. Which pathophysiological process contributes to this finding? - Answer-
Failure of the liver to convert ammonia absorbed from the bowel to urea.
A client with GERD is unconscious and unresponsive to stimuli. The nurse places the
client in a side-lying position. The nurse should monitor for the risk of which
complication? - Answer-Aspiration pneumonia.
A client returns to the unit after abdominal Nissen fundoplication for treatment of GERD.
After 4 hours, the nurse determines the client has no drainage from the NGT and has
absent bowel sounds. What action should the nurse implement? - Answer-Irrigate the
NGT with normal saline.
A male client who is admitted with a bleeding peptic ulcer develops sudden, severe
upper abdominal pain. The client becomes diaphoretic and draws his knees over his
abdomen. Which finding should the nurse report to the healthcare provider? - Answer-A
rigid, boardlike abdomen.
, A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for
treatment of a perforated ulcer. The healthcare provider's prescriptions include
morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low
intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of
increasing abdominal pain 12 hours after returning to the surgical unit. The nurse
determines the client has no bowel sounds, and 200 ml of bright red nasogastric
drainage is in the suction canister in the past hour. What is the priority action the nurse
should implement? - Answer-Notify HCP
A client returns from surgery after undergoing an abdominal-perineal resection with a
sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze
dressings. The perineal incision is partially closed with two drains attached to Jackson-
Pratt suction bulbs. During the early postoperative period, the nurse should give the
highest priority to which nursing action? - Answer-Maintain dry perineal dressings
What information in a client's history indicates the highest risk factor for hepatitis C? -
Answer-Intravenous drug abuse
A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting
ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from
his skin when he is turned. Which intervention is most important for the nurse to include
in the client's plan of care? - Answer-Apply a pressure-relieving mattress under the
client.
A female client arrives at the clinic because her boyfriend received the results of a Gram
stain smear that revealed the presence of Neisseria gonorrhoeae. The client tells the
nurse that she has not had any symptoms and almost did not come to the clinic. What
information should the nurse provide the client? - Answer-Gonorrhea is often
asymptomatic in women because the infection is not visible.
A client with an open reduction and application of an external fixator for open,
comminuted fractures of the tibia and fibula begins to complain of severe pain in the
affected leg, which is not relieved by analgesics. The client says the toes are numb and
tingling, although they appear pink. What action should the nurse implement? - Answer-
Notify HCP
A client is comatose upon arrival to the emergency department after falling from a roof.
The client flexes with painful stimuli, and the nurse determines the client's Glasgow
Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to
maintain the client's airway? - Answer-A nasopharyngeal tube.
The nurse is evaluating the external fetal monitor and identifies variable fetal heart rate
(FHR) decelerations. The nurse recognizes that this change in the FHR pattern is due to
which pathophysiological incident? - Answer-Umbilical cord compression
QUESTIONS WITH CORRECT ANSWERS
A 38-year-old female client is admitted to the mental health unit after a recent manic
episode of spending large amounts of money on new furniture, making excessive long-
distance phone calls, and not sleeping for three days. During the admission process,
the client is wearing a green bathing suit. What intervention should the nurse
implement? - Answer-Assess the client's needs for food, liquids, and rest.
During a group therapy session, a client with hypomania threatens to strike another
client. What intervention is best for the nurse to implement? - Answer-Firmly inform the
client that acting out anger is not acceptable.
A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and
multiple food allergies is scheduled for surgery. Which action should the nurse
implement? - Answer-Document a possible Type I latex allergy.
In reviewing the medical record, the nurse notes that a client's last eye examination
revealed an IOP of 28 mmHg. What information should the nurse ask the client? -
Answer-Use of prescribed eye drops since last exam by ophthalmologist.
Which action should the nurse implement to assess for JVD in a client with HF? -
Answer-Observe the vertical distention of the veins as the client is gradually elevated to
an upright position.
The nurse identifies a client's laboratory results and identifies an elevated serum
ammonia level. Which pathophysiological process contributes to this finding? - Answer-
Failure of the liver to convert ammonia absorbed from the bowel to urea.
A client with GERD is unconscious and unresponsive to stimuli. The nurse places the
client in a side-lying position. The nurse should monitor for the risk of which
complication? - Answer-Aspiration pneumonia.
A client returns to the unit after abdominal Nissen fundoplication for treatment of GERD.
After 4 hours, the nurse determines the client has no drainage from the NGT and has
absent bowel sounds. What action should the nurse implement? - Answer-Irrigate the
NGT with normal saline.
A male client who is admitted with a bleeding peptic ulcer develops sudden, severe
upper abdominal pain. The client becomes diaphoretic and draws his knees over his
abdomen. Which finding should the nurse report to the healthcare provider? - Answer-A
rigid, boardlike abdomen.
, A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for
treatment of a perforated ulcer. The healthcare provider's prescriptions include
morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low
intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of
increasing abdominal pain 12 hours after returning to the surgical unit. The nurse
determines the client has no bowel sounds, and 200 ml of bright red nasogastric
drainage is in the suction canister in the past hour. What is the priority action the nurse
should implement? - Answer-Notify HCP
A client returns from surgery after undergoing an abdominal-perineal resection with a
sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze
dressings. The perineal incision is partially closed with two drains attached to Jackson-
Pratt suction bulbs. During the early postoperative period, the nurse should give the
highest priority to which nursing action? - Answer-Maintain dry perineal dressings
What information in a client's history indicates the highest risk factor for hepatitis C? -
Answer-Intravenous drug abuse
A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting
ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from
his skin when he is turned. Which intervention is most important for the nurse to include
in the client's plan of care? - Answer-Apply a pressure-relieving mattress under the
client.
A female client arrives at the clinic because her boyfriend received the results of a Gram
stain smear that revealed the presence of Neisseria gonorrhoeae. The client tells the
nurse that she has not had any symptoms and almost did not come to the clinic. What
information should the nurse provide the client? - Answer-Gonorrhea is often
asymptomatic in women because the infection is not visible.
A client with an open reduction and application of an external fixator for open,
comminuted fractures of the tibia and fibula begins to complain of severe pain in the
affected leg, which is not relieved by analgesics. The client says the toes are numb and
tingling, although they appear pink. What action should the nurse implement? - Answer-
Notify HCP
A client is comatose upon arrival to the emergency department after falling from a roof.
The client flexes with painful stimuli, and the nurse determines the client's Glasgow
Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to
maintain the client's airway? - Answer-A nasopharyngeal tube.
The nurse is evaluating the external fetal monitor and identifies variable fetal heart rate
(FHR) decelerations. The nurse recognizes that this change in the FHR pattern is due to
which pathophysiological incident? - Answer-Umbilical cord compression
