RN Comprehensive Exam B: Questions and Answers, Exams of Nursing

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RN COMPREHENSIVE EXAM B

WITH QUESTIONS AND

ANSWERS RATED A+

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○ Garlic can be used to treat hypertension and elevated cholesterol levels. ■ Ginger can be used for nausea, vomiting, and motion sickness. ■ Gingko biloba can be used to increase blood flow to the brain and improve memory. ■ Saw palmetto can be used to treat urinary manifestations caused by benign prostatic hyperplasia. ● ○ Oral contraceptives increase the risk of thrombosis; therefore, the use of oral contraceptives is contraindicated when the client has a history of thrombophlebitis.

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○ A diet high in red meat and fat places the client at an increased risk for developing prostate cancer. ■ Exposure to arsenic, not creosote, places the client at an increased risk for developing prostate cancer. ■ Androgen therapy, not thyroid replacement therapy, places the client at an increased risk for developing prostate cancer. ● ○ The nurse should place the stethoscope midline and apply firm pressure just above the symphysis pubis to identify the fetal heart rate during the first trimester of pregnancy. ■ The nurse cannot measure uterine activity during the first trimester.

Evaluation of uterine activity requires an external tocotransducer. ■ Placing the Doppler stethoscope at the level of the umbilicus will not help to auscultate the fetal heart rate. The nurse should place the stethoscope midline just above the symphysis pubis. ■ The nurse cannot measure uterine activity during the first trimester using Leopold's maneuver. Leopold's maneuver helps to determine fetal presentation. ● ○ Medications used to treat tuberculosis have the possibility of damaging the liver. Drinking alcohol while taking these medications can increase this risk. Clients who are taking first-line medications for the treatment of tuberculosis should avoid consuming alcohol for the duration of treatment. ■ Clients who have been taking medications to treat tuberculosis for 2 to 3 consecutive weeks will no longer be contagious. However, clients will need to continue medication therapy for at least 6 months.

■ Clients who have tuberculosis will always have a positive Mantoux skin test. Three consecutive negative sputum tests will indicate that the client is no longer contagious. ■ Once diagnosed with tuberculosis, clients will require regular follow-up visits with the provider to track their recovery and contagion status. ● ○ The nurse should set up suctioning equipment at the bedside for use during a seizure to prevent aspiration. ■ The nurse should not keep both side rails in a raised position for a client who is at risk for seizures. Maintaining both side rails in a raised position can increase the client's risk for injury.

The newborn should have two plastic identification bracelets. One is on the arm and one is on the leg. The client's hospital identification number, name, date, time of the newborn's birth, and the newborn's sex are included. If one of these bands slides off or is missing, it should be replaced immediately. ● ○ This statement by the client indicates an understanding of the nurse's teaching. The retainer clip should be secured at the level of the infant's armpits to ensure safety. ■ Infants should remain in the rear-facing position until they are at least 2 years old to ensure safety. ■ The infant's car seat should be secured at a 45° angle to ensure safety. ● ○

■ Extra blankets or padding should not be added to the car seat because these could create extra air between the infant and the seat, which could cause injury to the infant during a motor-vehicle crash. ● ○ When using the survival potential approach to client care, the nurse should recommend the client who has a sucking chest wound be transported first. A client who has a sucking chest wound requires immediate intervention for survival. ■ A client who has a vascular injury with good peripheral circulation does not have an immediate threat to life and can wait several hours for treatment. ■ A client who has a low spinal cord injury does not have an immediate threat to life and can wait several hours for treatment. ■ A client who has agonal breathing is near the end of life and has a minimal chance of survival, even with extensive intervention.

○ The nurse should inject air into each vial being used to mix medications for administration. This action ensures that the nurse can easily withdraw the medication when needed and that the medication in the syringe is not pulled back into the vials due to negative pressure being formed. ■ The nurse should plan to use a 2-inch needle for an IM injection of this combination of the two medications. ■ The nurse should avoid administering more than 1 mL of medication into the deltoid site. Both haloperidol and diphenhydramine should be administered deep into a large muscle mass, such as the ventrogluteal muscle. ● ○ Marking the edges of stairs with paint or colored tape for contrast can help older adultclientswhohaveimpairedvisionpreventinjurybydecreasingtheriskoffalls. ●

○ Grapefruit juice inhibits metabolism of this medication, which results in a higher level of verapamil in the blood and causes hypotension. ● ○ Haloperidolhasanticholinergiceffects,suchasdrymouth .Thenurseshould inform the client that rinsing the mouth throughout the day, sucking on hard candy, or c hewingsugarlessgum canminimizedrymouth. ● ○ The client should take a stool softener to help avoid constipation, which is an adverseeffectofopioidanalgesics. ●

○ The nurse should monitor the client for any indications of bleeding after receiving alteplase, which can cause superficial bleeding from puncture sites such as invasive lines. epilepticus. ● ○ Thenurseshould piggybackthecefazolininfusionintothe0.9%sodiumchloride infusion after ensuring the solutions are compatible. ● ● ○ Thenurseshouldadministerlorazepam,abenzodiazepine,totreat status

■ The nurse should administer gabapentin for long-term management of seizures. ■ The nurse should administer carbamazepine for long- term management of seizures. ■ The nurse should administer valproic acid for long-term management of seizures. ● ○ The nurse should instruct the adolescent to cover the cast with plastic when bathing to keep the cast dry and intact. ■ The nurse should instruct the adolescent to apply ice for the first 24 hr to decrease pain and reduce swelling. ■ The nurse should instruct the adolescent to report any loss of sensation, numbness, tingling, and paralysis because this can indicate ischemia. ■ The nurse should instruct the adolescent to keep the leg elevated for the first 24 hr to reduce the risk of swelling and circulation impairment.

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○ A client who has vitamin B 12 deficiency anemia will have manifestations such as glossitis, which is a smooth, beefy-red tongue. ■ A client who has sickle cell anemia will experience jaundice of the sclera due to red blood cell destruction and release of bilirubin into the vascular system. ■ A client who has iron deficiency anemia will manifest fissures at the corners of the mouth due to lack of iron. ■ A client who has cold antibody anemia will experience blanching of the fingers. The disorder causes the arteries of the hands and feet to constrict in response to cold temperatures. “Your baby is breathing too fast to drink” - An infant who has ● ○

bronchiolitis might have tachypnea, in which case oral fluids are contraindicated and IV therapy should be instituted. ■ Antibiotics are not prescribed to treat bronchiolitis unless there is an underlying bacterial infection like otitis media or pneumonia. ■ IV therapy is initiated for the infant to maintain hydration status. It does not improve the condition of the infant's lungs because it does not include medication. ■ There is no indication the infant is experiencing hypotension. When using the airway, breathing, circulation approach to client care, the nurse determines that drooling is the priority finding to report to the provider. Drooling indicates obstruction and poor gas exchange, which might occur due to swelling or bleeding at the operative site. Other manifestations include difficulty swallowing, dyspnea, and stridor. ● ○

effect of carbon monoxide. ■ The nurse should expect a client who has carbon monoxide poisoning to experience muscle weakness rather than muscle rigidity. ■ The nurse should expect ulcerations in the oral cavity in a client who has an inhaled steam injury. ■ The nurse should expect singed nasal and facial hairs in a client who has a direct burn or injury. ● ○ Following surgery, the nurse should place the child in a position of comfort to facilitate drainage of secretions, such as semi-Fowler's position with their head to the side. ● ○ Thenurseshouldexpecttheclienttoexperiencehypotensionduetothe vasodilating

■ The nurse should instruct the child to avoid coughing and clearing their throat because this can aggravate the surgical site and cause bleeding, which can lead to hemorrhage. ■ The nurse should avoid administering liquids to the child through a straw because it can cause damage to the surgical site and result in bleeding. ■ The nurse should administer analgesics to the child every 4 hr for the first 24 to 48 hr to reduce pain and promote comfort. ● ○ The nurse should identify that abdominal pain can occur due to a perforation of the bowel, a potential complication of EGD. Therefore, the nurse should report abdominal pain to the provider. ■ Sore throat is an expected finding ■ Hypoactive bowel sounds is an expected finding

client who has multiple sclerosis. ■ Bradykinesia is slowness in movement and is a manifestation associated with a client who has Parkinson's disease. ■ Aphasia is the inability to speak and interpret language and is a manifestation associated with a client who had a stroke. ■ Fasciculations is twitching of the face and is a manifestation associated with a client who has amyotrophic lateral sclerosis. The drainage in the collection chamber is touching the tube - If the tube touches the drainage, it will impair suction and can lead to the ■ Flatulence isan expectedfinding ● ○ Nystagmus is involuntary eye movements and is a manifestation associated with a ● ○

development of a tension pneumothorax. The nurse should change out drainage systems before this occurs. ■ The chest tube collection device should be lower than the level of the client's chest to allow for draining. ■ The second chamber is a water seal chamber that tidals with inspiration and expiration. Occasionally, the water in the chamber might bubble when pressure within the intrathoracic area is greater than that of the atmosphere. This is an expected finding, but continuous bubbling indicates an air leak and would require further action. ■ The water seal chamber prevents air from re-entering the pleural space. This is done by the presence of water in the bottom of the chamber. At least 2 cm of water is necessary for this to work effectively. elevating blood glucose levels. ■ The nurse should instruct the client to fast overnight prior to testing to ensure accuracy of the results. ■ The nurse should instruct the client not to eat or drink during testing to ensure accuracy of the results. ● ○ Thenurseshouldinstructtheclienttoavoidcaffeine for 12 hr before the test to avoid

■ The nurse should instruct the client to maintain an unrestricted diet for 3 days prior to the test, including at least 150 g of carbohydrates each day. ● ○ The nurse should identify that unilateral tenderness of the left lower extremity can indicate the client is developing deep vein thrombosis. Therefore, unilateral tenderness of the left lower extremity should be reported to the provider immediately. ■ A low-grade fever is an expected finding for a client who is postoperative following a cesarean birth. ■ Uterine contractions during breastfeeding are an expected finding for a client who is postpartum. ■ Abdominal guarding when assessing the fundus is an expected finding for a client who is postpartum.

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○ To decrease the risk of CAUTI, evidence-based practice suggests performing periurethral care using mild soap and water. ■ To reduce the risk of CAUTI, the nurse should keep the drainage bag below the level of the client's bladder to prevent the reflux of urine from the drainage bag back into the bladder. ■ To reduce the risk of CAUTI, the nurse should identify that the indwelling urinary catheter should not be replaced routinely. ■ The nurse should use surgical aseptic technique when obtaining urine samples from the catheter port to prevent CAUTI.

The nurse should encourage the client to increase their fluid intake to promote hydration because dehydration increases the viscosity of the blood, which can increase the sickling process and lead to increased pain. ■ The nurse should keep the client's room temperature at or above 22.2° C (72° F) because cold temperatures cause vasoconstriction and promote sickling, which can increase the client's pain level. ■ The nurse should administer opioids as needed during a sickle cell crisis to manage the client’ s pain. ■ The nurse should encourage the client to keep their extremities extended to promote venous return. The nurse should teach the client that a frozen juice bar is an ● ○ ● ○

acceptable dessert and is included in a heart-healthy, low-sodium diet. Stepping forward with the weaker leg first demonstrates proper use of the quad cane. ■ The nurse should instruct the client to place the cane 15 to 25 cm (6 to 10 in) in front of the body prior to stepping forward. ■ The quad cane should always be placed on the stronger side of the body. ■ The nurse should instruct the client to keep the elbow flexed 15° when using the cane. ● ● ○

○ The nurse is responsible for evaluating that any task delegated to an LPN is correctly completed. Verifying the task and outcomes are documented in the client's medical record would indicate to the nurse that the task was completed. ● ○ The provider is responsible for the insertion of a central venous catheter. This procedure is outside the scope of practice for the RN. The nurse should inform the family member that they cannot share the client's ● ○

confidential medical information without permission from the client. The client must release information and determine with whom it can be shared. ■ The nurse should not share information about the client's condition without consent from the client. The client's family might not be aware of the client's HIV status; therefore, sharing this information with the client's family would be a breach of confidentiality. ● ○ The first action the nurse should take using the nursing process is to assess the staff's current knowledge of confidentiality requirements. ●

○ The guardian has the right to refuse the administration of erythromycin on behalf of their newborn. The nurse should have the guardian sign the refusal form and document it accordingly in the newborn's record. Performing postmortem care is within the range of function for an AP because it does not require client assessment and is included within the five rights of delegation: right task, right circumstances, right person, right direction, and right communication. ■ The nurse should identify that evaluation, including evaluating a client's alertness, is not within the range of function of an AP. ● ○ ● ○