comp 3 exam

Question 1

The nurse is reviewing newly written prescriptions for assigned clients. The nurse should follow up with the primary health care provider (HCP) on the client who has

Answer 1

Allergy to cephalosporin

Question 2

A nurse working on the pediatric unit has been made aware of the following information. Which of the following children should the nurse see first?

Answer 2

13 year old who has hemophilia and has a change in blood pressure from 112/60 to 90/54

Question 3

The nurse has instructed a female client on how to collect a midstream urine specimen. Which of the following client statements requires additional teaching by the nurse?

Answer 3

pee in toilet first then stop

Question 4

The nurse is observing a newly hired unlicensed assistive personnel care for assigned clients. The nurse should intervene if the newly hired UAP is observed

Answer 4

protective eyewear

Question 5

The nurse is caring for a client who is receiving peritoneal dialysis. Which of the following findings indicates that the client is having manifestations of peritonitis?

Answer 5

temp 100.7

Question 6

The nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on the left lower forearm. Which of the following actions should the nurse perform first?

Answer 6

apply pressure

Question 7

client with dropping BP and respirations with etoh abuse

Answer 7

flumazenil

Question 8

The charge nurse is assigning clients to a nurse who normally works in the maternal newborn unit and has been floated to the medical-surgical unit. Which of the following clients should the charge nurse assign to the float nurse?

Answer 8

c. Client who had an abdominal hysterectomy

Question 9

Cardiac strip what is the priority

Answer 9

defib the client

Question 10

the nurse is caring for a client whose arterial blood gas (ABG) results show the following pH 7.2, PaCo2 50, HCO3 24. Which of the following aceid-base imbalances should the nurse identify the client is experiencing - numbers changed go with

Answer 10

metabolic alkalosis

Question 11

the nurse is screening adult clients at a health fair. It is priority for the nurse to recommend follow up with a primary health care provider for the client who

Answer 11

55 year old, has a blood pressure of 164/96 and stopped smoking 2 months

Question 12

The nurse is preparing client assignments for the staff on the psychiatric unit. Which of the following clients should the nurse recognize as being at the highest risk for suicide?

Answer 12

70 year old male whose wife recently died and is giving away personal possessions

Question 13

The nurse is caring for a client who has anxiety disorder. The client is hyperventilating wronging their hands and pacing the room. Which of the following actions should the nurse take first?

Answer 13

stay with the client

Question 14

The nurse working in a pediatric health clinic has assessed the following clients. Which client findings indicates to the nurse the presence of developmental delay?

Answer 14

9 month old sit up

Question 15

The nurse working in the emergency department is caring for a client who sustained partial thickness burns to the chest, face, and both forearms. Which of the following actions is a priority for the nurse to take?

Answer 15

Inspecting for signs of inhalation injuries

Question 16

The nurse has provided discharge instructions to a mother who gave birth to a healthy, full term male. Which of the following statements by the mother indicates a correct understanding of the instructions?

Answer 16

cleanse the penis after each voiding by squeezing warm after over it

Question 17

A nurse has attended a conference about domestic violence. Which of the following statements made by the nurse indicates the need for additional teaching?

Answer 17

answer say high self-esteem and they really have low self-esteem

Question 18

The nurse working in the emergency department has been made aware of the following client situations. Which client information would require reporting by the nurse to an outside public health agency?

Answer 18

sti

Question 19

The nurse is teaching the partner of a client who had a stroke and has developed dysphagia. Which of the following statements by the client’s partner indicates a need for further teaching?

Answer 19

strawberries and juice

Question 20

The nurse is measuring a newborn’s chest circumstances. The nurse should place the tape measure at the

Answer 20

Nipple line

Question 21

The nurse is caring for a client who is receiving total parental nutrition (TPN). Which of the following requires a follow up by the nurse?

Answer 21

10% dextrose

Question 22

The nurse is caring for an older adult who has dementia and a history of falls. The nurse places the client in a chair that has a safety alarm. After a few minutes the safety alarm is triggered. The family overhears the nurse state to the client “I will need restraints in you if you keep sounding the alarm” Which of the following describes the statement made by the nurse?

Answer 22

defamation of character

Question 23

The nurse is assessing assigned clients for hospice services. The nurse should recommend hospice care for the client who

Answer 23

terminal disease

Question 24

The nurse preceptor is observing a newly hired nurse care for a client who is receiving a transfusion of packed red blood cells PRBC. The newly hired nurse stops the transfusion and implements the following actions. Which action requires immediate intervention by the nurse preceptor?

Answer 24

take it to the blood bank

Question 25

The nurse is providing discharge teaching to a young adult female who has been prescribed carbamazepine for seizures. Which of the following client statements indicates a correct understanding of the teaching?

Answer 25

I will notify my primary health care provider immediately if I develop a sore throat

Question 26

The nurse working on a pediatric unit has received the change of shift report and is reviewing client data and prescriptions. Which of the following clients should the nurse see first?

Answer 26

whooping cough

Question 27

The nurse is caring for a client who is in labor and has an external fetal monitor. The monitor strip indicates that the client is having persistent and constant late decelerations with 50% or more contractions. The nurse interprets that the client is experiencing

Answer 27

umbilical cord compression

Question 28

The nurse is caring for a female client who has right-sided paralysis secondary to a stroke. The client’s son states, “None of this would have happened if I had been there.” Which of the following responses should the nurse make?

Answer 28

feel responsible

Question 29

The nurse is caring for a client who frequently attempts to remove their feeding tube. The family has requested that a restraint be applied. Which of the following statements by the nurse is appropriate?

Answer 29

turn on soft music

Question 30

The nurse is teaching a client who has neutropenia and is preparing to go home. Which of the following statements should the nurse teach in the teaching?

Answer 30

spending time with her pregnant daughter and grandkids

Question 31

The nurse is working in an ambulatory health center has assessed the following clients who are waiting to see the primary health care provider. The nurse should immediately remove from the waiting room and place in an examine room the client who has

Answer 31

temperature

Question 32

The nurse is assessing an older adult client for urinary incontinence. Which of the following questions is important for the nurse to ask the client?

Answer 32

Do you ever use pads or tissues in your underwear to catch urine

Question 33

The nurse has instructed a client who has lung cancer and is receiving radiation therapy. Which of the following statements by the client would indicate a correct understanding of the teaching?

Answer 33

I will need to avoid raw fruits and vegetables while receiving radiation therapy

Question 34

The nurse working in an urgent care clinic is triaging the following clients. Which client should the nurse have assessed immediately by the primary health care provider?

Answer 34

46 year old client who is diaphoretic and reports epigastric pain

Question 35

The nurse is assessing a client who has syndrome pf inappropriate antidiuretic hormone SIADH. Which of the following should the nurse recognize as an expected finding?

Answer 35

Bounding pulse

Question 36

The nurse has instructed a client who has diabetes mellitus (type 1) about proper exercise. Which of the following client statements indicates the need for additional teaching?

Answer 36

do not exercise if blood glucose under 100

Question 37

The nurse is caring for a client who has heart failure and is taking digoxin daily. The client has refused and is reporting nausea, weakness, and blurred vision. Which of the following actions should the nurse take?

Answer 37

obtain vitals

Question 38

The charge nurse reviewing client’s electronic medical records. Which documentations by a nurse staff would indicate need for additional teaching?

Answer 38

phlebitis in the arm

Question 39

The nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. It would indicate that the client is having an expected outcome of the medication if the client demonstrates a decrease in

Answer 39

unknown answer

Question 40

The nurse is caring for a client who has a new prescription for graduated compression stockings. Which of the following actions should the nurse take?

Answer 40

measure the circumference of leg

Question 41

The nurse is caring for a client who has urinary incontinence and is at risk for skin breakdown. Which of the following actions should the nurse implement as a preventive measure?

Answer 41

Apply a moisture barrier ointment to the skin

Question 42

The nurse is caring for a client who has urinary incontinence and is at risk for skin breakdown. Which of the following actions should the nurse implement as a preventive measure?

Answer 42

Apply a moisture barrier ointment to the skin

Question 43

The nurse is caring for a client who had a kidney transplant 1 week ago. It is a priority for the nurse to notify the health care provider if the client

Answer 43

flank pain

Question 44

The Registered nurse is planning care for clients and is assigning tasks to a licensed practical/vocational nurse and unlicensed assistive personnel. Which of following tasks should the RN assign to LPN/VN?

Answer 44

heparin pt is over 60

Question 45

The nurse working in a medical-surgical unit is aware of the following situations. Which situation requires the nurse to complete an incident report?

Answer 45

phlebitis

Question 46

The nurse is caring for a client who has just returned from having a sigmoid colon resection. The client lost about 400 mL of blood intraoperative has an indwelling urethral catheter draining clear yellow urine and IV infusion of lactated Ringers at 150 mL/hr. Which of the following findings indicates to the nurse that the client may be developing hypovolemic shock?

Answer 46

pulse 88 to 120

Question 47

The nurse is caring for a client who is prescribed warfarin for a prosthetic heart valve. Which of the following findings indicates a therapeutic effect of the medication

Answer 47

pt 60 seconds

Question 48

The nurse is preparing to administer scheduled immunization to a pediatric client who is immunocompromised. Which of the following immunizations should the nurse question

Answer 48

live influenza vaccine

Question 49

The nurse is teaching a client who is scheduled to have a permanent pacemaker implanted. Which of the following should the nurse include in the teaching?

Answer 49

Avoid lifting the arm above the head on the side that your pacemaker inserted until the primary health care provider says otherwise

Question 50

The nurse is preparing to teach a client who has anemia and new prescription for liquid ferrous sulfate. Which of the following instructions should the nurse include in the teaching

Answer 50

Mix the medication with orange juice and use a straw when drinking the dose