LATEST NURS 3365 FINAL -
COMPREHENSIVE NURSING EXAM |
COMPLETE EXAM WITH CORRECT
ANSWERS AND RATIONALES. A+
GUARANTEED SUCCESS
1. A nurse is using the nursing process to care for a
client. Which action occurs during the
implementation phase?
A) Collecting subjective and objective data
B) Analyzing data to identify nursing diagnoses
C) Carrying out nursing interventions
D) Determining whether client outcomes were
achieved
Correct answer: C
Rationale: Implementation involves carrying out
nursing interventions (actions) to achieve client
outcomes. Assessment collects data. Diagnosis
analyzes data. Evaluation determines outcome
achievement.
,2. A nurse is prioritizing client care using Maslow
hierarchy of needs. Which client should the nurse
address first?
A) A client who reports feeling anxious about an
upcoming surgery
B) A client with a new colostomy who needs teaching
about appliance changes
C) A client with a respiratory rate of 32 and oxygen
saturation of 88%
D) A client who requests pain medication for a
headache
Correct answer: C
Rationale: Maslow hierarchy prioritizes physiological
needs (airway, breathing, circulation, oxygen) before
safety, love/belonging, esteem, and self-
actualization. The client with respiratory distress has
an immediate physiological need.
3. A nurse is preparing to administer a blood
transfusion. Which intravenous solution is compatible
with blood products?
A) 5% dextrose in water
B) 0.9% normal saline
C) Lactated Ringer solution
,D) 0.45% normal saline
Correct answer: B
Rationale: Only 0.9% normal saline is compatible with
blood products. Dextrose solutions cause hemolysis.
Lactated Ringer contains calcium, which can activate
the clotting cascade. Hypotonic solutions cause red
blood cell lysis.
4. A nurse is caring for a client who is postoperative
and has a patient-controlled analgesia (PCA) pump.
The client is somnolent and has a respiratory rate of 8
breaths per minute. What is the priority action?
A) Instruct the client to take deep breaths
B) Stop the PCA infusion and notify the provider
C) Increase the PCA lockout interval
D) Apply oxygen at 2 L per minute via nasal cannula
Correct answer: B
Rationale: A respiratory rate of 8 with somnolence
indicates opioid-induced respiratory depression. The
PCA infusion should be stopped immediately, and the
provider should be notified. Oxygen and stimulation
are supportive but do not address the cause.
, 5. A nurse is assessing a client who is 2 hours
postoperative after abdominal surgery. Which finding
requires immediate intervention?
A) The client reports pain of 6 on a 0-to-10 scale
B) The client's heart rate is 110 beats per minute and
blood pressure is 90/50 mm Hg
C) The client's oxygen saturation is 94% on room air
D) The client has not yet voided
Correct answer: B
Rationale: Tachycardia with hypotension in the
postoperative period may indicate hypovolemia from
hemorrhage or dehydration and requires immediate
assessment. Pain is expected. Oxygen saturation of
94% is acceptable. Not voiding at 2 hours is not yet
concerning.
6. A nurse is preparing to administer an
intramuscular injection of vitamin K to a newborn.
Which site is most appropriate?
A) Ventrogluteal
B) Dorsogluteal
C) Vastus lateralis
D) Deltoid
Correct answer: C
COMPREHENSIVE NURSING EXAM |
COMPLETE EXAM WITH CORRECT
ANSWERS AND RATIONALES. A+
GUARANTEED SUCCESS
1. A nurse is using the nursing process to care for a
client. Which action occurs during the
implementation phase?
A) Collecting subjective and objective data
B) Analyzing data to identify nursing diagnoses
C) Carrying out nursing interventions
D) Determining whether client outcomes were
achieved
Correct answer: C
Rationale: Implementation involves carrying out
nursing interventions (actions) to achieve client
outcomes. Assessment collects data. Diagnosis
analyzes data. Evaluation determines outcome
achievement.
,2. A nurse is prioritizing client care using Maslow
hierarchy of needs. Which client should the nurse
address first?
A) A client who reports feeling anxious about an
upcoming surgery
B) A client with a new colostomy who needs teaching
about appliance changes
C) A client with a respiratory rate of 32 and oxygen
saturation of 88%
D) A client who requests pain medication for a
headache
Correct answer: C
Rationale: Maslow hierarchy prioritizes physiological
needs (airway, breathing, circulation, oxygen) before
safety, love/belonging, esteem, and self-
actualization. The client with respiratory distress has
an immediate physiological need.
3. A nurse is preparing to administer a blood
transfusion. Which intravenous solution is compatible
with blood products?
A) 5% dextrose in water
B) 0.9% normal saline
C) Lactated Ringer solution
,D) 0.45% normal saline
Correct answer: B
Rationale: Only 0.9% normal saline is compatible with
blood products. Dextrose solutions cause hemolysis.
Lactated Ringer contains calcium, which can activate
the clotting cascade. Hypotonic solutions cause red
blood cell lysis.
4. A nurse is caring for a client who is postoperative
and has a patient-controlled analgesia (PCA) pump.
The client is somnolent and has a respiratory rate of 8
breaths per minute. What is the priority action?
A) Instruct the client to take deep breaths
B) Stop the PCA infusion and notify the provider
C) Increase the PCA lockout interval
D) Apply oxygen at 2 L per minute via nasal cannula
Correct answer: B
Rationale: A respiratory rate of 8 with somnolence
indicates opioid-induced respiratory depression. The
PCA infusion should be stopped immediately, and the
provider should be notified. Oxygen and stimulation
are supportive but do not address the cause.
, 5. A nurse is assessing a client who is 2 hours
postoperative after abdominal surgery. Which finding
requires immediate intervention?
A) The client reports pain of 6 on a 0-to-10 scale
B) The client's heart rate is 110 beats per minute and
blood pressure is 90/50 mm Hg
C) The client's oxygen saturation is 94% on room air
D) The client has not yet voided
Correct answer: B
Rationale: Tachycardia with hypotension in the
postoperative period may indicate hypovolemia from
hemorrhage or dehydration and requires immediate
assessment. Pain is expected. Oxygen saturation of
94% is acceptable. Not voiding at 2 hours is not yet
concerning.
6. A nurse is preparing to administer an
intramuscular injection of vitamin K to a newborn.
Which site is most appropriate?
A) Ventrogluteal
B) Dorsogluteal
C) Vastus lateralis
D) Deltoid
Correct answer: C
