Comprehensive B
1. The nurse has been made aware of the following client situations. It is necessary for the nurse
to initially assess the client who has:
a. Diabetes mellitus (type 1), is difficult to arouse, and has a blood glucose of 38 mg/dL.
b. A urinary tract infection (UTI), is receiving oral (PO) cephalexin, and reports urinary
frequency.
c. Community-acquired pneumonia (CAP), has a white blood cell (WBC) count of 18,400/mm3,
and is scheduled to receive IV vancomycin.
d. Appendicitis, reports pain rated 3 on a scale of 0 (no pain) to 10 (severe pain), and needs
assistance ambulating to the bathroom.
2. The nurse has received the hand-off report and is assigning tasks to unlicensed assistive
personnel (UAP). Which of the following tasks should the nurse instruct the UAP to perform
first?
a. Obtain a sputum specimen from a client who has suspected pulmonary tuberculosis (TB).
b. Turn and reposition a client who was last turned 2 hours ago.
c. Deliver a lunch tray to a client who is returning from radiology and has been NPO since
breakfast.
d. Obtain a capillary blood glucose on a client who had a hypoglycemia episode 30 minutes ago
and received dextrose IV.
3. The nurse working on a pediatric unit has received the hand-off report and is reviewing client
data and orders. Which of the following clients should the nurse plan to see first?
a. The toddler who has bilateral arm casts and needs to be fed their breakfast.
b. The school-aged child who has diabetes mellitus (type 1) and requires blood glucose
monitoring.
c. The infant who has a diagnosis of pertussis and is receiving oxygen via nasal cannula.
d. The adolescent who was admitted with sickle cell crisis and is being discharged home.
4. The nurse who normally works on the maternity unit has been floated to work on an adult
medical surgical unit for the shift. It is appropriate to assign the float nurse the client who:
a. Is being discharged home and needs teaching about dressing changes to a wound.
, b. Is 24 hours postoperative from having an appendectomy.
c. Was admitted the night before with chronic obstructive pulmonary disease (COPD).
d. Is scheduled to have an above-the-knee amputation (AKA) that morning.
5. The nurse preceptor is observing a newly hired nurse teach a client who has pelvic
inflammatory disease about self-care. The client does not speak English. Which of the following
actions by the newly hired nurse requires intervention by the nurse preceptor?
a. Providing written instructions to the client in their primary language.
b. Contacting the charge nurse to obtain assistance from a facility approved interpreter.
c. Having a family member who speaks both English and the client’s language interpret the
instructions.
d. Utilizing a facility-approved telephone interpretation service to conduct the teaching.
6. The nurse working in the labor and delivery (L&D) unit is caring for a client in labor whose
membranes just spontaneously ruptured. Which of the following findings is a priority for the
nurse to report to the primary health care provider (PHCP)?
a. A maternal temperature (T) of 99.5 F.
b. New appearance of late decelerations.
c. 4 contractions in a 10-minute period.
d. Contractions lasting 60 seconds.
7. The nurse preceptor is observing a newly hired nurse care for assigned clients. Which of the
following actions by the newly hired nurse indicates correct care?
a. Using a 23-gauge, 1-inch needle when administering a medication in the deltoid muscle.
b. Placing a particular respirator (N95) mask on a client who has active pulmonary tuberculosis
(TB) in preparation for transport to a long-term care (LTC) facility.
c. Administering oral pain medication to a client 20-minutes prior to hospital discharge.
d. Teaching a client who has a new ileostomy to empty the ostomy bag 30 minutes after eating a
meal.
1. The nurse has been made aware of the following client situations. It is necessary for the nurse
to initially assess the client who has:
a. Diabetes mellitus (type 1), is difficult to arouse, and has a blood glucose of 38 mg/dL.
b. A urinary tract infection (UTI), is receiving oral (PO) cephalexin, and reports urinary
frequency.
c. Community-acquired pneumonia (CAP), has a white blood cell (WBC) count of 18,400/mm3,
and is scheduled to receive IV vancomycin.
d. Appendicitis, reports pain rated 3 on a scale of 0 (no pain) to 10 (severe pain), and needs
assistance ambulating to the bathroom.
2. The nurse has received the hand-off report and is assigning tasks to unlicensed assistive
personnel (UAP). Which of the following tasks should the nurse instruct the UAP to perform
first?
a. Obtain a sputum specimen from a client who has suspected pulmonary tuberculosis (TB).
b. Turn and reposition a client who was last turned 2 hours ago.
c. Deliver a lunch tray to a client who is returning from radiology and has been NPO since
breakfast.
d. Obtain a capillary blood glucose on a client who had a hypoglycemia episode 30 minutes ago
and received dextrose IV.
3. The nurse working on a pediatric unit has received the hand-off report and is reviewing client
data and orders. Which of the following clients should the nurse plan to see first?
a. The toddler who has bilateral arm casts and needs to be fed their breakfast.
b. The school-aged child who has diabetes mellitus (type 1) and requires blood glucose
monitoring.
c. The infant who has a diagnosis of pertussis and is receiving oxygen via nasal cannula.
d. The adolescent who was admitted with sickle cell crisis and is being discharged home.
4. The nurse who normally works on the maternity unit has been floated to work on an adult
medical surgical unit for the shift. It is appropriate to assign the float nurse the client who:
a. Is being discharged home and needs teaching about dressing changes to a wound.
, b. Is 24 hours postoperative from having an appendectomy.
c. Was admitted the night before with chronic obstructive pulmonary disease (COPD).
d. Is scheduled to have an above-the-knee amputation (AKA) that morning.
5. The nurse preceptor is observing a newly hired nurse teach a client who has pelvic
inflammatory disease about self-care. The client does not speak English. Which of the following
actions by the newly hired nurse requires intervention by the nurse preceptor?
a. Providing written instructions to the client in their primary language.
b. Contacting the charge nurse to obtain assistance from a facility approved interpreter.
c. Having a family member who speaks both English and the client’s language interpret the
instructions.
d. Utilizing a facility-approved telephone interpretation service to conduct the teaching.
6. The nurse working in the labor and delivery (L&D) unit is caring for a client in labor whose
membranes just spontaneously ruptured. Which of the following findings is a priority for the
nurse to report to the primary health care provider (PHCP)?
a. A maternal temperature (T) of 99.5 F.
b. New appearance of late decelerations.
c. 4 contractions in a 10-minute period.
d. Contractions lasting 60 seconds.
7. The nurse preceptor is observing a newly hired nurse care for assigned clients. Which of the
following actions by the newly hired nurse indicates correct care?
a. Using a 23-gauge, 1-inch needle when administering a medication in the deltoid muscle.
b. Placing a particular respirator (N95) mask on a client who has active pulmonary tuberculosis
(TB) in preparation for transport to a long-term care (LTC) facility.
c. Administering oral pain medication to a client 20-minutes prior to hospital discharge.
d. Teaching a client who has a new ileostomy to empty the ostomy bag 30 minutes after eating a
meal.
