COMPREHENSIVE EXAM 3 REVIEWED QUESTIONS
WITH ANSWERS 100%
A,38-year-
old,female,client,is,admitted,to,the,mental,health,unit,after,a,recent,manic,episode,of,spending,large,amo
unts,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?,ANS,-
Assess,the,client's,needs,for,food,,liquids,,and,rest.
During,a,group,therapy,session,,a,client,with,hypomania,threatens,to,strike,another,client.,What,intervent
ion,is,best,for,the,nurse,to,implement?,ANS,-
Firmly,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,aller
gies,is,scheduled,for,surgery.,Which,action,should,the,nurse,implement?,ANS,-
Document,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?,ANS,-
Use,of,prescribed,eye,drops,since,last,exam,by,ophthalmologist.
Which,action,should,the,nurse,implement,to,assess,for,JVD,in,a,client,with,HF?,ANS,-
Observe,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,p
athophysiological,process,contributes,to,this,finding?,ANS,-
Failure,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?,ANS,-Aspiration,pneumonia.
A,client,returns,to,the,unit,after,abdominal,Nissen,fundoplication,for,treatment,of,GERD.,After,4,hours,,th
e,nurse,determines,the,client,has,no,drainage,from,the,NGT,and,has,absent,bowel,sounds.,What,action,sh
ould,the,nurse,implement?,ANS,-Irrigate,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,re
port,to,the,healthcare,provider?,ANS,-A,rigid,,boardlike,abdomen.
A,client,returns,to,the,postoperative,unit,after,a,gastroduodenostomy,(Billroth,I),for,treatment,of,a,perfor
ated,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,an
d,antibiotics.,The,client,complains,of,increasing,abdominal,pain,12,hours,after,returning,to,the,surgical,uni
t.,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?,ANS,-
Notify,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,wh
ich,nursing,action?,ANS,-Maintain,dry,perineal,dressings
What,information,in,a,client's,history,indicates,the,highest,risk,factor,for,hepatitis,C?,ANS,-
Intravenous,drug,abuse
A,client,with,advanced,cirrhosis,and,hepatic,encephalopathy,is,manifesting,mounting,ascites,and,4+,pittin
g,edema,of,the,feet,and,legs.,The,nurse,identifies,fluid,leaking,from,his,skin,when,he,is,turned.,Which,inter
vention,is,most,important,for,the,nurse,to,include,in,the,client's,plan,of,care?,ANS,-Apply,a,pressure-
relieving,mattress,under,the,client.
A,female,client,arrives,at,the,clinic,because,her,boyfriend,received,the,results,of,a,Gram,stain,smear,that,r
evealed,the,presence,of,Neisseria,gonorrhoeae.,The,client,tells,the,nurse,that,she,has,not,had,any,sympto
ms,and,almost,did,not,come,to,the,clinic.,What,information,should,the,nurse,provide,the,client?,ANS,-
Gonorrhea,is,often,asymptomatic,in,women,because,the,infection,is,not,visible.
A,client,with,an,open,reduction,and,application,of,an,external,fixator,for,open,,comminuted,fractures,of,t
he,tibia,and,fibula,begins,to,complain,of,severe,pain,in,the,affected,leg,,which,is,not,relieved,by,analgesics
.,The,client,says,the,toes,are,numb,and,tingling,,although,they,appear,pink.,What,action,should,the,nurse,i
mplement?,ANS,-Notify,HCP