Comprehensive Exam 3 Questions with 100% Correct Answers: Nursing, Exams of Nursing

Download Comprehensive Exam 3 Questions with 100% Correct Answers: Nursing and more Exams Nursing in PDF only on Docsity! COMPREHENSIVE EXAM 3 QUESTIONS WITH 100% CORRECT ANSWERS 2024- 2025 UPDATED GRADED A +. 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? - Exact answerAssess 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? - Exact answerFirmly 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? - Exact answerDocument 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? - Exact answerUse of prescribed eye drops since last exam by ophthalmologist. Which action should the nurse implement to assess for JVD in a client with HF? - Exact answerObserve 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? - Exact answerFailure 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? - Exact answerAspiration 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? - Exact answerIrrigate 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? - Exact answerA rigid, board like 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? - Exact answerNotify 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? - Exact answerMaintain dry perineal dressings What information in a client's history indicates the highest risk factor for hepatitis C? - Exact answerIntravenous 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? - Exact answerApply a pressure-relieving mattress under the client. should recognize that the mother plays which function when planning this child's care? - Exact answerAn expert in care of the child. The parents of a 5-year-old are concerned because their child showed more outward grief when a pet died than when a sibling died from sudden infant death syndrome (SIDS). What response should the nurse provide? - Exact answerThe child focuses on another connection because the sibling's death is misunderstood The nurse is planning care for a child with Trisomy 21 who is admitted with recurrent upper respiratory infections and chronic constipation. Which intervention should the nurse include in the plan of care? - Exact answerUse a bedside cool-mist vaporizer during naps and night time. The parents of a 4-month-old infant who is hospitalized tell the nurse that they have to work and cannot stay with the baby except on weekends. Which actions should the nurse-manager implement to address the infant's emotional needs? - Exact answerAssign the same nurse to care for the child each day. The nurse is catheterizing a 7-year-old boy who has been admitted to the pediatric unit. After cleansing the glans penis, what should the nurse do first to minimize discomfort? - Exact answerInsert 5 ml of 2% lidocaine lubricant into the urethra. The nurse is suctioning the tracheostomy for a child who is experiencing rhonchi and unable to expel mucus. Which action should the nurse implement to provide effective pulmonary toileting? - Exact answerEach pass of the suction catheter should take no longer than five seconds. The nurse is assessing a client who is receiving risperidone (Risperdal). The nurse should monitor the client for which common side effect that is most likely to occur during therapy? - Exact answerWeight gain A client is receiving an opioid analgesic every 2 hours for intractable pain. Which pathophysiological consequence should the nurse identify if the client receives the medication at regular intervals? - Exact answerRespiratory acidosis. A client who is taking nitroglycerin for angina is concerned about having headaches after taking more than one tablet. What information should the nurse provide? - Exact answerThis is a common side effect due to the vasodilatory effects of the medication. A male client with gastric cancer is 1 week postoperative for a total gastrectomy and has normal hematologic parameters. Which vitamin should the nurse explain to the client is indicated to take for his lifetime? - Exact answerVitamin B12 A client is prescribed a STAT dose of IV insulin. Which vial should the nurse select to prepare the dose? - Exact answerInsulin regular (Humulin R). Before administering timolol maleate (Timoptic) to a client with open-angled glaucoma, which finding should the nurse report to the healthcare provider? - Exact answerReceives carvedilol (Coreg) for heart failure (HF). The neonatologist requests a mother to provide breast milk for her 32-week gestational premature newborn. The nurse provides instructions about pumping, storing, and transporting the breast milk. Which additional information should the nurse include to ensure the mother understands the request? - Exact answerProviding breast milk ensures the premature newborn can easily digest and absorb the nutrients. Three days after a colon resection, the nurse is assessing a client with a nasogastric tube (NGT) to intermittent suction. What assessment should the nurse implement to determine proper placement of the NGT? - Exact answerAspirate the tube contents to test the pH. In which order should the nurse implement these actions when withdrawing a solution from an ampule? - Exact answerFlick the stem several times with a finger. Wrap the neck with a protective device. Break the neck by pressing thumbs outward. Stabilize ampule on a firm surface. Withdraw the solution using a filter needle. When administering an intramuscular (IM) injection to an adult client using the ventrogluteal site, which landmarks should the nurse identify to locate the area for injection? - Exact answerThe anterosuperior iliac spine and the greater trochanter. The nurse identifies a break in sterile technique as a client is draped for an operative procedure. What action should the nurse implement? - Exact answerPoint out the observation immediately to the surgical team. The nurse is supervising an unlicensed assistive personnel (UAP) who is feeding an older client with dysphagia. Which action by the UAP requires the nurse's intervention? - Exact answerDivides solid food items into one inch cube pieces The nurse instills an atropine ophthalmic solution into both eyes for a client who is having a routine eye examination. Which side effects should the nurse tell the client to anticipate? - Exact answerBlurred vision client is using an otic solution, hydrocortisone and polymyxin B (Otobiotic otic), for external otitis media. Which therapeutic response should the nurse tell the client to expect? - Exact answerDecreases inflammation and pain The nurse is providing tracheostomy care for a client who has encrusted secretions inside the inner cannula. Which solution should the nurse use to remove the debris? - Exact answerhydrogen peroxide The nurse is instructing a client about the use of podofilox (Condylox) for the treatment of genital warts. Which information should the nurse provide? - Exact answerRedness, peeling, and itching may occur at the site of application. The nurse is reviewing the laboratory results of an older client who is admitted to a medical unit. Which serum chemistry values should the nurse recognize as most commonly affected by the aging process? (Select all that apply.) - Exact answerCalcium Potassium Sodium During admission to the mental health unit, a female client with bipolar disorder, manic phase, is loud, hyperverbal, hyperactive, and is garishly dressed. Which intervention should the nurse include when planning care Which intervention demonstrates the nurse's accountability in a specific decision-making process? - Exact answerEvaluating a client's outcomes after implementation of care. A male client gives a copy of his living will to the nurse upon admission to the hospital. What action should the nurse implement if the client is unable to express his desire about life-prolonging measures? - Exact answerAllow the client to die with dignity and without life-prolonging techniques. Which individual may legally sign an informed consent? - Exact answerA 16-year-old mother for her newborn Which nursing diagnosis is best to formulate for a 76-year-old client who is exhibiting an external locus of control? - Exact answerPowerlessness At what phase of the therapeutic relationship should the nurse ask a male client about his reasons for seeking medical care and hospitalization? - Exact answerOrientation phase An adolescent client is admitted to the mental health unit for impulsivity and acting-out behavior at school. What intervention should the nurse implement that is most beneficial for this client? - Exact answerExplain the consequences for breaking the unit rules Which entry in the client's medical record provides the best documentation of client care? - Exact answer0830- IV fluid rate increased to 100 ml/hour according to protocol. An older client who is admitted with terminal cancer of the liver begins to talk with the nurse about spiritual life after death. Which response by the nurse best assesses the client's spiritual needs? - Exact answer"I notice you have a Bible" Which change in sleep patterns is most likely to occur in an older adult? - Exact answerHas a decline in stage 4 sleep The nurse is developing the plan of care for an older client who is immobile and at risk for pressure ulcers. Which contributing factor should the nurse include in the nursing diagnosis, "Risk for altered skin integrity? - Exact answerTissue ischemia A male client tells the nurse that he is frequently constipated. Which finding should the nurse identify as a common dietary cause of constipation? - Exact answerInadequate intake of dietary fiber and fluids The nurse is obtaining a client's consent for a paracentesis. Which information should the nurse provide to ensure the client understands the purpose of the procedure? - Exact answerA needle is inserted to remove excessive fluid from the abdominal peritoneal cavity. The nurse is teaching a client with Addison's disease about this new diagnosis. What pathophysiological explanation should the nurse share with the client? - Exact answerAdrenal insufficiency is an autoimmune dysfunction that results from white blood cells damaging the adrenal cortex The healthcare provider prescribes digital evacuation of a fecal impaction for an older client who is admitted with a closed head injury after falling out of bed. As a part of the procedure policy, the nurse applies a topical anesthetic gel to the rectum. Which rationale best supports the use of the anesthetic gel? - Exact answerDecrease risk for bradycardia What nursing intervention should the nurse include in the plan of care for a client following a bone marrow aspiration? - Exact answerUse of a compression dressing for firm pressure to the site The nurse identifies the nursing diagnosis of, Visual sensory/perceptual alterations related to increased intraocular pressure (IOP) for a client with glaucoma. Which nursing intervention should the nurse include in the plan of care? - Exact answerEncourage compliance with drug therapy to prevent loss of vision. Which client information should the nurse obtain that is indicative of the presence of cholelithiasis? - Exact answerUpper right abdominal pain that occurs after meals and radiates to the back or right shoulder. Which intervention is most important for the nurse to include in the plan of care for a client with ankylosing spondylitis? - Exact answerInitiate a smoking cessation program. A male client has a prescription for disulfiram (Antabuse). Which adverse reaction should the nurse caution the client about while taking the medication? - Exact answerVomiting The nurse is evaluating a client's response to diuretic therapy. Which assessment provides the best measure of the client's fluid volume status? - Exact answerIntake, output, and daily weight A 32-year-old male client is admitted with paranoid schizophrenia. The nurse observes the client walking around the unit muttering to himself and gesturing as if he is having auditory hallucinations. Which action provides the most effective psychotherapeutic management? - Exact answerReassure the client that he is safe and should rest. Which family-centered care concept(s) should the nurse encourage family members to use to promote child growth, development, and independence? - Exact answerEnabling and empowerment A mother asks the nurse to explain how using time-out to discipline her 2- year-old child is an effective method. Which rationale should the nurse provide? - Exact answerRemoves a reinforcer that a child is receiving The nurse is caring for a client who is one-day post cardiac catheterization with stent placement. Assessment findings are: blood pressure 90/40, heart rate 45 beats/minute, and oxygen saturation at 95% on oxygen nasal cannula at 2 L/minute. Which task should the nurse delegate to the unlicensed assistive personnel (UAP) at this time? - Exact answerObtain urine output for the past 4 hours. The nurse notes a client with decreased alertness is having difficulty managing saliva. What is the priority assessment for the nurse to implement prior to feeding? - Exact answerPresence of a gag reflex Pulse oximetry is being used to monitor a client's oxygen saturation. Which client risk factor(s) should the nurse consider as variable(s) that affect this measurement? (Select all that apply.) - Exact answerSmoking Jaundice Hypotension Type 1 diabetes mellitus Which assessment finding should the nurse identify in an adult client with sleep deprivation? - Exact answerMood swings and irritability What clinical problem is a suitable for research utilization in nursing? - Exact answerThe value of calcium channel blockers use over ACE inhibitors The nurse manager is explaining to a new nurse that the nursing units at the hospital are managed by the nursing staff who control self-scheduling of shift work, implement unit quality improvement program, and participate in unit recruitment-retention programs. What type of management model is the nurse manager describing? - Exact answerOperational shared governance What description encompasses the role in client care management played by nursing informatics? - Exact answerThe input and retrieval of electronic data about a client's medical history During a mass casualty incident involving a 1000 or more victims, which action is the priority for the nurse to implement? - Exact answerPrioritize care for victims The nurse manager is developing a plan to increase the local population's utilization of a new community-based public clinic. Which approach should the nurse utilize to obtain the most impact on developing a collaborative partnership with the community? - Exact answerConduct a focus group in community to gather data on culturally significant needs A male client with degenerative arthritis of the knees and hips takes an OTC NSAID for pain. During a routine clinic visit, the client tells the nurse, "For the past month I've been having a lot of trouble sleeping. I can't seem to fall asleep, and when I finally do get sleep, I find that I wake up a number of times during the night." Which info should the nurse obtain first? - Exact answerHow intense does the client rate his pain on a scale of 1-10? on the second day after admission, a client with a fractured pelvis develops chest pain, tachypnea, and tachycardia. Which additional finding should the nurse identify that is most likely related to a fat embolism - Exact answerpetechiae of the anterior chest wall The nurse is assessing an adult who displays stagnation,.... - Exact answerGenerativity versus stagnation The nurse is caring for a client with diabetic ketoacidosis - Exact answerKussmaul respirations The nurse is teaching a client who is newly diagnosed with Type 1 diabetes mellitus about diet and insulin - Exact answerShakiness Which action should the nurse implement when providing nasogastric (NG) feeding to an unresponsive client - Exact answerCheck residual volume every four hours. A client is admitted with myasthenia gravi - Exact answerPtosis The nurse enters a client's room to complete discharge preps and finds the client in tears. the client states that someone fro the business office insisted that a payment for the hospital bill be made before the client could leave. After providing comfort to the client, what is the best nursing action? - Exact answerContinue the client's discharge process The nurse is providing care for a 6-year-old boy who has a broken arm and multiple bruises - Exact answerReport the situation to appropriate authorities A client with cellulitis is recovering at home after experiencing a severe reaction - Exact answerA malpractice suit based on lack of reasonable and prudent care The nurse places a heating pad on the lower leg.. - Exact answerAll elements are present to find the nurse liable for damages which action by the nurse-manager demonstrates an effective leadership style - Exact answerFosters positive behavior changes in staff members