COMPREHENSIVE EXAM 3 QUESTIONS
AND ANSWERS. VERIFIED 2026.
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? - 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 intervention 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 allergies 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.
@COPYRIGHT 2026/2027 ALL RIGHTS RESERVED
1
,The nurse identifies a client's laboratory results and identifies an elevated serum ammonia
level. Which pathophysiological 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, the nurse determines the client has no drainage from the NGT and has absent bowel
sounds. What action should 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 report 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 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? - 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 which
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
@COPYRIGHT 2026/2027 ALL RIGHTS RESERVED
2
, 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? - 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 revealed the presence of Neisseria gonorrhoeae. The client tells the nurse that she
has not had any symptoms 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 the 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 implement? - ANS Notify HCP
A client is comatose upon arrival to the emergency department after falling from a roof. The
client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale
(GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's
airway? - ANS A nasopharyngeal tube.
The nurse is evaluating the external fetal monitor and identifies variable fetal heart rate (FHR)
decelerations. The nurse recognizes that this change in the FHR pattern is due to which
pathophysiological incident? - ANS Umbilical cord compression
Which FHR finding should the nurse report to the HCP immediately? - ANS Late decelerations
A mother brings her 4-week-old infant for the first well-child visit and tells the nurse that the
baby is not smiling. Which information should the nurse provide? - ANS Social smiling begins
at approximately 2 months of age
The nurse is explaining dietary management to a client with pregestational diabetes during a
prenatal visit. Which client statement indicates that the teaching has been effective? -
ANS Diet and insulin needs will change significantly throughout my pregnancy.
@COPYRIGHT 2026/2027 ALL RIGHTS RESERVED
3
AND ANSWERS. VERIFIED 2026.
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? - 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 intervention 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 allergies 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.
@COPYRIGHT 2026/2027 ALL RIGHTS RESERVED
1
,The nurse identifies a client's laboratory results and identifies an elevated serum ammonia
level. Which pathophysiological 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, the nurse determines the client has no drainage from the NGT and has absent bowel
sounds. What action should 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 report 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 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? - 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 which
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
@COPYRIGHT 2026/2027 ALL RIGHTS RESERVED
2
, 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? - 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 revealed the presence of Neisseria gonorrhoeae. The client tells the nurse that she
has not had any symptoms 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 the 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 implement? - ANS Notify HCP
A client is comatose upon arrival to the emergency department after falling from a roof. The
client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale
(GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's
airway? - ANS A nasopharyngeal tube.
The nurse is evaluating the external fetal monitor and identifies variable fetal heart rate (FHR)
decelerations. The nurse recognizes that this change in the FHR pattern is due to which
pathophysiological incident? - ANS Umbilical cord compression
Which FHR finding should the nurse report to the HCP immediately? - ANS Late decelerations
A mother brings her 4-week-old infant for the first well-child visit and tells the nurse that the
baby is not smiling. Which information should the nurse provide? - ANS Social smiling begins
at approximately 2 months of age
The nurse is explaining dietary management to a client with pregestational diabetes during a
prenatal visit. Which client statement indicates that the teaching has been effective? -
ANS Diet and insulin needs will change significantly throughout my pregnancy.
@COPYRIGHT 2026/2027 ALL RIGHTS RESERVED
3
