100 Item Comprehensive Nursing Exam
With Answers
1. The nurse enters the room as a 3 year-old is having a generalized seizure.
Which intervention should the nurse do first?
A) Clear the area of any hazards
B) Place the child on the side
C) Restrain the child
D) Give the prescribed anticonvulsant - correct answers✅✅The correct
answer is B: Place the child on the side
Protecting the airway is the top priority in a seizure. If a child is actively
convulsing, a patent airway and oxygenation must be assured.
2. A client has just returned to the medical-surgical unit following a
segmental lung resection. After assessing the client, the first nursing action
would be to
A) Administer pain medication
B) Suction excessive tracheobronchial secretions
C) Assist client to turn, deep breath and cough
D) Monitor oxygen saturation - correct answers✅✅The correct answer is
B: Suction excessive tracheobronchial secretions
Suctioning the copious tracheobronchial secretions present in post-thoracic
surgery clients maintains an open airway which is always the priority nursing
intervention.
3. A nurse from the surgical department is reassigned to the pediatric unit.
The charge nurse should recognize that the child at highest risk for cardiac
arrest and is the least likely to be assigned to this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
,100 Item Comprehensive Nursing Exam
With Answers
D) Severe multiple trauma - correct answers✅✅The correct answer is C:
Prolonged hypoxemia Most often, the cause of cardiac arrest in the pediatric
population is prolonged hypoxemia. Children usually have both cardiac and
respiratory arrest.
4. Which of the following would be the best strategy for the nurse to use
when teaching insulin injection techniques to a newly diagnosed client with
diabetes?
A) Give written pre and posttests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration - correct answers✅✅The correct
answer is D: Observe a return demonstration
Since this is a psychomotor skill, this is the best way to know if the client has
learned the proper technique.
5. The nurse is assessing a 2-year-old client with a possible diagnosis of
congenital heart disease. Which of these is most likely to be seen with this
diagnosis?
A) Several otitis media episodes in the last year
B) Weight and height in 10th percentile since birth
C) Takes frequent rest periods while playing
D) Changing food preferences and dislikes - correct answers✅✅The
correct answer is C: Takes frequent rest periods while playing.
Children with heart disease tend to have exercise intolerance. The child self-
limits activity, which is consistent with manifestations of congenital heart
disease in children.
, 100 Item Comprehensive Nursing Exam
With Answers
6. The nurse is reassigned to work at the Poison Control Center telephone
hotline. In which of these cases of childhood poisoning would the nurse
suggest that parents have the child drink orange juice?
A) An 18 month-old who ate an undetermined amount of crystal drain
cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an
empty bottle of diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid -
correct answers✅✅The correct answer is A: An 18 month-old who ate an
undetermined amount of crystal drain cleaner.
Drain cleaner is very alkaline. The orange juice is acidic and will help to
neutralize this substance.
7. A 23-year-old single client is in the 33rd week of her first pregnancy. She
tellsthe nurse that she has everything ready for the baby and has made
plans for the first weeks together at home. Which normal emotional reaction
does the nurse recognize?
A) Acceptance of the pregnancy
B) Focus on fetal development
C) Anticipation of the birth
D) Ambivalence about pregnancy - correct answers✅✅The correct answer
is C: Anticipation of the birth
Directing activities toward preparation for the newborn's needs and personal
adjustment are indicators of appropriate emotional response in the third
trimester.
8. Upon examining the mouth of a 3-year-old child, the nurse discovers that
the teeth have chalky white-to-yellowish staining with pitting of the enamel.
Which of the following conditions would most likely explain these findings?
With Answers
1. The nurse enters the room as a 3 year-old is having a generalized seizure.
Which intervention should the nurse do first?
A) Clear the area of any hazards
B) Place the child on the side
C) Restrain the child
D) Give the prescribed anticonvulsant - correct answers✅✅The correct
answer is B: Place the child on the side
Protecting the airway is the top priority in a seizure. If a child is actively
convulsing, a patent airway and oxygenation must be assured.
2. A client has just returned to the medical-surgical unit following a
segmental lung resection. After assessing the client, the first nursing action
would be to
A) Administer pain medication
B) Suction excessive tracheobronchial secretions
C) Assist client to turn, deep breath and cough
D) Monitor oxygen saturation - correct answers✅✅The correct answer is
B: Suction excessive tracheobronchial secretions
Suctioning the copious tracheobronchial secretions present in post-thoracic
surgery clients maintains an open airway which is always the priority nursing
intervention.
3. A nurse from the surgical department is reassigned to the pediatric unit.
The charge nurse should recognize that the child at highest risk for cardiac
arrest and is the least likely to be assigned to this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
,100 Item Comprehensive Nursing Exam
With Answers
D) Severe multiple trauma - correct answers✅✅The correct answer is C:
Prolonged hypoxemia Most often, the cause of cardiac arrest in the pediatric
population is prolonged hypoxemia. Children usually have both cardiac and
respiratory arrest.
4. Which of the following would be the best strategy for the nurse to use
when teaching insulin injection techniques to a newly diagnosed client with
diabetes?
A) Give written pre and posttests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration - correct answers✅✅The correct
answer is D: Observe a return demonstration
Since this is a psychomotor skill, this is the best way to know if the client has
learned the proper technique.
5. The nurse is assessing a 2-year-old client with a possible diagnosis of
congenital heart disease. Which of these is most likely to be seen with this
diagnosis?
A) Several otitis media episodes in the last year
B) Weight and height in 10th percentile since birth
C) Takes frequent rest periods while playing
D) Changing food preferences and dislikes - correct answers✅✅The
correct answer is C: Takes frequent rest periods while playing.
Children with heart disease tend to have exercise intolerance. The child self-
limits activity, which is consistent with manifestations of congenital heart
disease in children.
, 100 Item Comprehensive Nursing Exam
With Answers
6. The nurse is reassigned to work at the Poison Control Center telephone
hotline. In which of these cases of childhood poisoning would the nurse
suggest that parents have the child drink orange juice?
A) An 18 month-old who ate an undetermined amount of crystal drain
cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an
empty bottle of diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid -
correct answers✅✅The correct answer is A: An 18 month-old who ate an
undetermined amount of crystal drain cleaner.
Drain cleaner is very alkaline. The orange juice is acidic and will help to
neutralize this substance.
7. A 23-year-old single client is in the 33rd week of her first pregnancy. She
tellsthe nurse that she has everything ready for the baby and has made
plans for the first weeks together at home. Which normal emotional reaction
does the nurse recognize?
A) Acceptance of the pregnancy
B) Focus on fetal development
C) Anticipation of the birth
D) Ambivalence about pregnancy - correct answers✅✅The correct answer
is C: Anticipation of the birth
Directing activities toward preparation for the newborn's needs and personal
adjustment are indicators of appropriate emotional response in the third
trimester.
8. Upon examining the mouth of a 3-year-old child, the nurse discovers that
the teeth have chalky white-to-yellowish staining with pitting of the enamel.
Which of the following conditions would most likely explain these findings?
