RN COMPREHENSIVE PREDICTOR FORM C ACTUAL
EXAM WITH COMPLETE SOLUTION
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The
nurse obtained a verbal prescription for restraints. Which of the following should the actions the
nurse take?
Request a renewal of the prescription every 8 hr.
Check the client's peripheral pulse rate every 30 min
Obtain a prescription for restraint within 4 hr.
Document the client's condition every 15 minutes - ✔✔Document the client's condition every
15 minutes
A nursing planning care for a school-age child who is 4 hr postoperative following perforated
appendicitis. Which of the following actions should the nurse include in the plan of care?
Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
Give cromolyn nebulizer solution every 6 hr (for asthma)
Apply a warm compress to the operative site every 4 hr
Administer analgesics on a scheduled basis for the first 24 hr - ✔✔Administer analgesics on a
scheduled basis for the first 24 hr
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
should the nurse plan to assess first?
A client who has sinus arrhythmia and is receiving cardiac monitoring A client who has diabetes
mellitus and a hemoglobin A1C of 6.8%
A client who has epidural analgesia and weakness in the lower extremities
A client who has a hip fracture and a new onset of tachypnea - ✔✔A client who has a hip
fracture and a new onset of tachypnea
,A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following
actions should the nurse take?
Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote
absorption; avoid oily or broken skin)
Wear gloves to apply the patch to the client's skin
Apply the patch within 1 hr of removing it from the protective pouch (apply immediately)
Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed
together) - ✔✔Wear gloves to apply the patch to the client's skin
A nurse has just received change-of-shift report for four clients. Which of the following clients
should the nurse assess first?
A client who was just given a glass of orange juice for a low blood glucose level
A client who is scheduled for a procedure in an hour
A client who has 100 mL fluid remaining in his IV bag (can wait)
A client who received a pain medication 30 min ago for postoperative pain - ✔✔A client who
was just given a glass of orange juice for a low blood glucose level
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the
following places the client at risk for aspiration?
A history of gastroesophageal reflux disease
Receiving a high osmolarity formula
Sitting in a high-Fowler's position during the feeding
A residual of 65 mL 1hr postprandial - ✔✔A history of gastroesophageal reflux disease
A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse
should expect the client to have an increase in which of the following laboratory values?
a. Serum glucose level- increased
,b. Serum calcium level decreased
c. Lymphocyte Count
d. Serum Potassium Level - ✔✔a. Serum glucose level- increased
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate
intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity.
Which of the following actions should the nurse take?
Position the client supine
Prepare an IV bolus of dextrose 5% in water
Administer methylergonovine IM
Administer calcium gluconate IV - ✔✔Administer calcium gluconate IV
Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of
calcium gluconate available when administering magnesium sulfate by IV.
A charge nurse is teaching new staff members about factors that increase a client's risk to
become violent. Which of the following risk factors should the nurse include as the best predictor
of future violence?
Experiencing delusions
Male gender
Previous violent behavior
A history of being in prison - ✔✔Previous violent behavior
Risk factors also include: past history of aggression, poor impulse control, and violence.
Comorbidity that leads to acts of violence (psychotic delusions, command
hallucinations, violent angry reactions with cognitive disorders). Individual Assessment for
Violence
, A nurse is preparing to perform a sterile dressing change. Which of the following actions should
the nurse take when setting up the sterile field?
Place the cap from the solution sterile side up on clean surfaceb. Open the outermost flap of the
sterile kit toward the body→ flap AWAY from the body's first
Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch)
border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field
5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level - ✔
✔Place the cap from the solution sterile side up on clean surfaceb.
A nurse is providing teaching to an older adult client about methods to promote nighttime sleep.
Which of the following instructions should the nurse include?
Eat a light snack before bedtime
Stay in bed at least 1hr if unable to fall asleep
Take a 1hr nap during the day
Perform excercises prior to bedtime - ✔✔Eat a light snack before bedtime
A home health nurse is preparing for an initial visit with an older adult client who lives alone.
Which of the following actions should the nurse take first?
A. Educate the client about current medical diagnosis
B. Refer the client to a meal delivery program
C. Identify environmental hazards in the home
D. Arrange for client transportation to follow-up - ✔✔C. Identify environmental hazards in the
home
A nurse is assessing the remote memory of an older adult client who has mild dementia. Which
of the following questions should the nurse ask the client?
"Can you tell me who visited you today?"
"What high school did you graduate from"
EXAM WITH COMPLETE SOLUTION
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The
nurse obtained a verbal prescription for restraints. Which of the following should the actions the
nurse take?
Request a renewal of the prescription every 8 hr.
Check the client's peripheral pulse rate every 30 min
Obtain a prescription for restraint within 4 hr.
Document the client's condition every 15 minutes - ✔✔Document the client's condition every
15 minutes
A nursing planning care for a school-age child who is 4 hr postoperative following perforated
appendicitis. Which of the following actions should the nurse include in the plan of care?
Offer small amounts of clear liquids 6 hr following surgery (assess for gag reflex first)
Give cromolyn nebulizer solution every 6 hr (for asthma)
Apply a warm compress to the operative site every 4 hr
Administer analgesics on a scheduled basis for the first 24 hr - ✔✔Administer analgesics on a
scheduled basis for the first 24 hr
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
should the nurse plan to assess first?
A client who has sinus arrhythmia and is receiving cardiac monitoring A client who has diabetes
mellitus and a hemoglobin A1C of 6.8%
A client who has epidural analgesia and weakness in the lower extremities
A client who has a hip fracture and a new onset of tachypnea - ✔✔A client who has a hip
fracture and a new onset of tachypnea
,A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following
actions should the nurse take?
Shave hairy areas of skin prior to application (apply to hairless, clean & dry areas to promote
absorption; avoid oily or broken skin)
Wear gloves to apply the patch to the client's skin
Apply the patch within 1 hr of removing it from the protective pouch (apply immediately)
Remove the previous patch and place it in a tissue (fold patch in half with sticky sides pressed
together) - ✔✔Wear gloves to apply the patch to the client's skin
A nurse has just received change-of-shift report for four clients. Which of the following clients
should the nurse assess first?
A client who was just given a glass of orange juice for a low blood glucose level
A client who is scheduled for a procedure in an hour
A client who has 100 mL fluid remaining in his IV bag (can wait)
A client who received a pain medication 30 min ago for postoperative pain - ✔✔A client who
was just given a glass of orange juice for a low blood glucose level
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the
following places the client at risk for aspiration?
A history of gastroesophageal reflux disease
Receiving a high osmolarity formula
Sitting in a high-Fowler's position during the feeding
A residual of 65 mL 1hr postprandial - ✔✔A history of gastroesophageal reflux disease
A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse
should expect the client to have an increase in which of the following laboratory values?
a. Serum glucose level- increased
,b. Serum calcium level decreased
c. Lymphocyte Count
d. Serum Potassium Level - ✔✔a. Serum glucose level- increased
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate
intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity.
Which of the following actions should the nurse take?
Position the client supine
Prepare an IV bolus of dextrose 5% in water
Administer methylergonovine IM
Administer calcium gluconate IV - ✔✔Administer calcium gluconate IV
Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of
calcium gluconate available when administering magnesium sulfate by IV.
A charge nurse is teaching new staff members about factors that increase a client's risk to
become violent. Which of the following risk factors should the nurse include as the best predictor
of future violence?
Experiencing delusions
Male gender
Previous violent behavior
A history of being in prison - ✔✔Previous violent behavior
Risk factors also include: past history of aggression, poor impulse control, and violence.
Comorbidity that leads to acts of violence (psychotic delusions, command
hallucinations, violent angry reactions with cognitive disorders). Individual Assessment for
Violence
, A nurse is preparing to perform a sterile dressing change. Which of the following actions should
the nurse take when setting up the sterile field?
Place the cap from the solution sterile side up on clean surfaceb. Open the outermost flap of the
sterile kit toward the body→ flap AWAY from the body's first
Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch)
border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field
5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level - ✔
✔Place the cap from the solution sterile side up on clean surfaceb.
A nurse is providing teaching to an older adult client about methods to promote nighttime sleep.
Which of the following instructions should the nurse include?
Eat a light snack before bedtime
Stay in bed at least 1hr if unable to fall asleep
Take a 1hr nap during the day
Perform excercises prior to bedtime - ✔✔Eat a light snack before bedtime
A home health nurse is preparing for an initial visit with an older adult client who lives alone.
Which of the following actions should the nurse take first?
A. Educate the client about current medical diagnosis
B. Refer the client to a meal delivery program
C. Identify environmental hazards in the home
D. Arrange for client transportation to follow-up - ✔✔C. Identify environmental hazards in the
home
A nurse is assessing the remote memory of an older adult client who has mild dementia. Which
of the following questions should the nurse ask the client?
"Can you tell me who visited you today?"
"What high school did you graduate from"
