COMP Galen College of nursing Questions with Complete Solutions
Course
COMP
1. A nurse is assessing a client with heart failure who reports shortness of breath
and fatigue. Which of the following findings should the nurse recognize as a
priority?
A. 3+ pitting edema in the lower extremities
B. Weight gain of 3 lb in 2 days
C. Blood pressure of 98/58 mm Hg
D. Oxygen saturation of 88% on room air
Correct Answer: D. Oxygen saturation of 88% on room air
Rationale: The priority in this scenario is maintaining adequate oxygenation. An oxygen
saturation of 88% indicates hypoxia and requires immediate intervention. While weight gain,
edema, and low BP are concerning for fluid overload, they are not as immediately life-
threatening as hypoxia.
2. A client receiving heparin therapy for deep vein thrombosis has an aPTT of 90
seconds. Which action should the nurse take?
A. Increase the heparin infusion rate
B. Continue monitoring the client
C. Stop the heparin infusion and notify the provider
D. Administer protamine sulfate
Correct Answer: C. Stop the heparin infusion and notify the provider
Rationale: A normal aPTT range is 30-40 seconds (therapeutic range: 1.5-2.5 times normal, or
~60-80 seconds). A value of 90 seconds is dangerously high, increasing the risk of bleeding. The
priority is stopping heparin and notifying the provider. Protamine sulfate is the antidote, but the
provider must decide whether to administer it.
3. A nurse is teaching a client about proper insulin administration. The client is
prescribed NPH and regular insulin. Which statement by the client indicates a
need for further teaching?
,A. "I will draw up the regular insulin before the NPH insulin."
B. "I will rotate injection sites to prevent lipodystrophy."
C. "I should shake the NPH insulin bottle before drawing it up."
D. "I can administer insulin in my abdomen, arm, or thigh."
Correct Answer: C. "I should shake the NPH insulin bottle before drawing it up."
Rationale: NPH insulin should be rolled between the hands, not shaken, to prevent air bubbles
and ensure proper mixing. The other statements are correct regarding insulin administration.
4. A client with a history of chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy at 4 L/min via nasal cannula. The nurse notes
confusion and drowsiness. What is the priority action?
A. Increase the oxygen flow rate
B. Lower the oxygen flow rate
C. Encourage the client to cough and deep breathe
D. Check the client’s blood glucose level
Correct Answer: B. Lower the oxygen flow rate
Rationale: Clients with COPD rely on hypoxic drive to breathe. High oxygen levels can
suppress their respiratory drive, leading to CO₂ retention and respiratory depression (as seen
with confusion and drowsiness). Oxygen should typically be kept at 1-2 L/min unless otherwise
directed by the provider.
5. A nurse is caring for a client who has hypokalemia. Which assessment finding
is most concerning?
A. Muscle cramps
B. Irregular heart rate
C. Decreased deep tendon reflexes
D. Fatigue
Correct Answer: B. Irregular heart rate
Rationale: Hypokalemia (low potassium) can cause life-threatening arrhythmias (e.g.,
ventricular dysrhythmias). While muscle cramps, decreased reflexes, and fatigue are expected,
cardiac irregularities require immediate intervention.
,6. A nurse is reviewing the medication orders for a client prescribed digoxin.
Which lab value requires immediate intervention?
A. Sodium 138 mEq/L
B. Digoxin level 2.5 ng/mL
C. Potassium 4.2 mEq/L
D. BUN 18 mg/dL
Correct Answer: B. Digoxin level 2.5 ng/mL
Rationale: The therapeutic range for digoxin is 0.5-2.0 ng/mL. A level of 2.5 ng/mL suggests
digoxin toxicity, which can cause nausea, vomiting, vision changes, and life-threatening
arrhythmias.
7. A client with schizophrenia states, "The government is controlling my
thoughts through the TV." What is the most appropriate response by the nurse?
A. "That sounds frightening. Tell me more about what you're feeling."
B. "The government is not controlling your thoughts."
C. "Let’s talk about something else to distract you."
D. "You need to stop watching so much television."
Correct Answer: A. "That sounds frightening. Tell me more about what you're feeling."
Rationale: This response validates the client’s emotions while avoiding agreement with the
delusion. Challenging or dismissing delusions can increase client distress.
8. A nurse is preparing to administer a blood transfusion. Which action is most
important before starting the infusion?
A. Verify the client’s blood type and crossmatch
B. Warm the blood bag before administration
C. Allow the blood to hang for up to 6 hours
D. Prime the IV line with dextrose solution
Correct Answer: A. Verify the client’s blood type and crossmatch
Rationale: Mismatched blood transfusion can be fatal. Always verify the client’s blood type,
crossmatch, and two-patient identifiers before administration. Blood should not be warmed
unless ordered, must be used within 4 hours, and should be primed with normal saline (not
dextrose) to prevent hemolysis.
, 9. A nurse is assessing a client who has just received morphine for post-op pain.
Which finding requires immediate intervention?
A. Respiratory rate of 8 breaths/min
B. Heart rate of 90 bpm
C. Drowsiness
D. BP of 118/76 mm Hg
Correct Answer: A. Respiratory rate of 8 breaths/min
Rationale: Respiratory depression (<10 breaths/min) is a severe adverse effect of opioids.
The nurse should administer naloxone (Narcan) if needed and monitor closely.
10. A nurse is caring for a postpartum client experiencing heavy vaginal
bleeding. What is the first action the nurse should take?
A. Administer oxytocin IV
B. Massage the fundus
C. Call the healthcare provider
D. Insert a Foley catheter
Correct Answer: B. Massage the fundus
Rationale: Uterine atony is the most common cause of postpartum hemorrhage. The first action
is to massage the fundus to stimulate contraction. If ineffective, oxytocin may be given, and the
provider should be notified.
11. A nurse is teaching a client with newly diagnosed iron-deficiency anemia about dietary
sources of iron. Which meal selection indicates the client understands the teaching?
A. Baked chicken, mashed potatoes, and apple slices
B. Grilled salmon, brown rice, and steamed broccoli
C. Spinach salad with steak strips and a glass of orange juice
D. Cheese pizza with a side of carrot sticks
Correct Answer: C. Spinach salad with steak strips and a glass of orange juice
Rationale: Red meats (like steak) and leafy greens (like spinach) are rich in iron. Vitamin C
(orange juice) enhances iron absorption, making this the best choice.
Course
COMP
1. A nurse is assessing a client with heart failure who reports shortness of breath
and fatigue. Which of the following findings should the nurse recognize as a
priority?
A. 3+ pitting edema in the lower extremities
B. Weight gain of 3 lb in 2 days
C. Blood pressure of 98/58 mm Hg
D. Oxygen saturation of 88% on room air
Correct Answer: D. Oxygen saturation of 88% on room air
Rationale: The priority in this scenario is maintaining adequate oxygenation. An oxygen
saturation of 88% indicates hypoxia and requires immediate intervention. While weight gain,
edema, and low BP are concerning for fluid overload, they are not as immediately life-
threatening as hypoxia.
2. A client receiving heparin therapy for deep vein thrombosis has an aPTT of 90
seconds. Which action should the nurse take?
A. Increase the heparin infusion rate
B. Continue monitoring the client
C. Stop the heparin infusion and notify the provider
D. Administer protamine sulfate
Correct Answer: C. Stop the heparin infusion and notify the provider
Rationale: A normal aPTT range is 30-40 seconds (therapeutic range: 1.5-2.5 times normal, or
~60-80 seconds). A value of 90 seconds is dangerously high, increasing the risk of bleeding. The
priority is stopping heparin and notifying the provider. Protamine sulfate is the antidote, but the
provider must decide whether to administer it.
3. A nurse is teaching a client about proper insulin administration. The client is
prescribed NPH and regular insulin. Which statement by the client indicates a
need for further teaching?
,A. "I will draw up the regular insulin before the NPH insulin."
B. "I will rotate injection sites to prevent lipodystrophy."
C. "I should shake the NPH insulin bottle before drawing it up."
D. "I can administer insulin in my abdomen, arm, or thigh."
Correct Answer: C. "I should shake the NPH insulin bottle before drawing it up."
Rationale: NPH insulin should be rolled between the hands, not shaken, to prevent air bubbles
and ensure proper mixing. The other statements are correct regarding insulin administration.
4. A client with a history of chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy at 4 L/min via nasal cannula. The nurse notes
confusion and drowsiness. What is the priority action?
A. Increase the oxygen flow rate
B. Lower the oxygen flow rate
C. Encourage the client to cough and deep breathe
D. Check the client’s blood glucose level
Correct Answer: B. Lower the oxygen flow rate
Rationale: Clients with COPD rely on hypoxic drive to breathe. High oxygen levels can
suppress their respiratory drive, leading to CO₂ retention and respiratory depression (as seen
with confusion and drowsiness). Oxygen should typically be kept at 1-2 L/min unless otherwise
directed by the provider.
5. A nurse is caring for a client who has hypokalemia. Which assessment finding
is most concerning?
A. Muscle cramps
B. Irregular heart rate
C. Decreased deep tendon reflexes
D. Fatigue
Correct Answer: B. Irregular heart rate
Rationale: Hypokalemia (low potassium) can cause life-threatening arrhythmias (e.g.,
ventricular dysrhythmias). While muscle cramps, decreased reflexes, and fatigue are expected,
cardiac irregularities require immediate intervention.
,6. A nurse is reviewing the medication orders for a client prescribed digoxin.
Which lab value requires immediate intervention?
A. Sodium 138 mEq/L
B. Digoxin level 2.5 ng/mL
C. Potassium 4.2 mEq/L
D. BUN 18 mg/dL
Correct Answer: B. Digoxin level 2.5 ng/mL
Rationale: The therapeutic range for digoxin is 0.5-2.0 ng/mL. A level of 2.5 ng/mL suggests
digoxin toxicity, which can cause nausea, vomiting, vision changes, and life-threatening
arrhythmias.
7. A client with schizophrenia states, "The government is controlling my
thoughts through the TV." What is the most appropriate response by the nurse?
A. "That sounds frightening. Tell me more about what you're feeling."
B. "The government is not controlling your thoughts."
C. "Let’s talk about something else to distract you."
D. "You need to stop watching so much television."
Correct Answer: A. "That sounds frightening. Tell me more about what you're feeling."
Rationale: This response validates the client’s emotions while avoiding agreement with the
delusion. Challenging or dismissing delusions can increase client distress.
8. A nurse is preparing to administer a blood transfusion. Which action is most
important before starting the infusion?
A. Verify the client’s blood type and crossmatch
B. Warm the blood bag before administration
C. Allow the blood to hang for up to 6 hours
D. Prime the IV line with dextrose solution
Correct Answer: A. Verify the client’s blood type and crossmatch
Rationale: Mismatched blood transfusion can be fatal. Always verify the client’s blood type,
crossmatch, and two-patient identifiers before administration. Blood should not be warmed
unless ordered, must be used within 4 hours, and should be primed with normal saline (not
dextrose) to prevent hemolysis.
, 9. A nurse is assessing a client who has just received morphine for post-op pain.
Which finding requires immediate intervention?
A. Respiratory rate of 8 breaths/min
B. Heart rate of 90 bpm
C. Drowsiness
D. BP of 118/76 mm Hg
Correct Answer: A. Respiratory rate of 8 breaths/min
Rationale: Respiratory depression (<10 breaths/min) is a severe adverse effect of opioids.
The nurse should administer naloxone (Narcan) if needed and monitor closely.
10. A nurse is caring for a postpartum client experiencing heavy vaginal
bleeding. What is the first action the nurse should take?
A. Administer oxytocin IV
B. Massage the fundus
C. Call the healthcare provider
D. Insert a Foley catheter
Correct Answer: B. Massage the fundus
Rationale: Uterine atony is the most common cause of postpartum hemorrhage. The first action
is to massage the fundus to stimulate contraction. If ineffective, oxytocin may be given, and the
provider should be notified.
11. A nurse is teaching a client with newly diagnosed iron-deficiency anemia about dietary
sources of iron. Which meal selection indicates the client understands the teaching?
A. Baked chicken, mashed potatoes, and apple slices
B. Grilled salmon, brown rice, and steamed broccoli
C. Spinach salad with steak strips and a glass of orange juice
D. Cheese pizza with a side of carrot sticks
Correct Answer: C. Spinach salad with steak strips and a glass of orange juice
Rationale: Red meats (like steak) and leafy greens (like spinach) are rich in iron. Vitamin C
(orange juice) enhances iron absorption, making this the best choice.
