EXAM
RATED BEST
lO
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VATI RN Comprehensive Predictor
1. A community health nurse is evaluating eligibility for home assistance for a client
who is quadriplegic. Which of the following actions should the nurse perform first?
a. Determine the client's living situation.
b. Problem solved with the client.
c. Offer community resources to the client.
d. Assist the client with decision-making.
2. A nurse is discussing care with a newly licensed nurse for a client who practices Orthodox
Judaism. Which of the following meals suggestions by the newly licensed nurse indicates a
needfor further teaching?
a. Chicken breast and boiled potatoes.
b. Carrot sticks and cottage cheese.
c. Grilled cheese an Apple
sauce.d. Roast beef and ice
cream.
3. A nurse is preparing to auscultate a client apical pulse at the point of maximal impulse
(PMI). thenurse should place the diaphragm of the stethoscope at which of the following
locations
a. Within the angle of Louis.
b. 5th intercostal space at the left midclavicular line.
c. Second intercostal space to the right of the sternum.
d. Over the xyphoid process.
4. A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hour and
develops a hemolytic reaction. Which of the following actions should the nurse perform?
a. Infuse 0.9% sodium chloride IV.
b. Administer an anti-pyretic.
c. Decrease the infusion rate to 75 mL/hour.
d. Place the client in a left lateral position
5. A nurse is planning care for a client who is prescribed a cane for ambulation. Which
of thefollowing nursing actions should the nurse include in the plan of care?
a. Remind the client to place the cane on the unaffected side.
b. Adjust the length of the cane to equal the distance from the client's iliac crest to the
floor.
c. Remove the rubber tip from the cane to enhance ambulation.
d. Place the King safely in the closet during naps and at bedtime.
6. Nurse is caring for a client who had a partial laryngectomy and is receiving continuous
enteralfeedings at 65 mL/hour through a gastrostomy tube. Which of the following
findings requires immediate intervention by the nurse?
a. The gastric residual volume is 250 mL following two hours of
infusion. b. The client is lying in a supine position.
c. The infusion pump for administering continuous feeding is turned off.
d. Interior feeding bag and tubing are not dated.
7. A nurse is caring for a group of clients which of the following tasks is appropriate for the
nurse to delegate to the assistive personnel (AP)? (Select all that apply.)
a. change addressing for a client who has a stage three decubitus
ulcer.b. Measure I&O for a client who is receiving peritoneal
dialysis.
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c. Transfer client from bed to chair with mechanical lift.
d. Provide postmortem care on a client who experienced cardiac arrest.
e. Obtain a signed consent for a client for a screening colonoscopy.
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8. A nurse is planning care for a newborn who has hyper bilirubinemia and is to
receive phototherapy. Which of the following interventions should the nurse
include?
a. Cloth the newborn in light cotton
b. Check the newborns temperature every 8 hours.
c. Administer 120 mL of water between feedings.
d. Place the newborn 45 cm (18 in) from the light source.
9. An assistive personnel tells the nurse that several client measurements were
obtained withmorning vital signs. Which of the following clients should the nurse
plan to assess?
a. A 4-year-old who has a closed head injury and a heart rate of 60/min
10. A nurse is caring for a client following possible exposure to anthrax. Which of the
followingactions should the nurse take?
a. Administer an antitoxin
b. Quarantine the client.
c. Monitor the client for a productive cough.
d. Being prophylactic treatment with ciprofloxacin
11. A nurse is providing teaching about car seat safety to the parent of a term newborn.
Which of thefollowing statements by the parent indicates an understanding of the
teaching?
a. I should place a rolled blanket along each side of my baby's head in the car seat.
b. I should place my baby's car seat rear facing until six months of age.
c. I should put the car seat retainer clip at the end of my baby's belly button.
d. I should position my baby's car seat at a 90-degree angle in the car.
12. A nurse is assessing an infant who has water intoxication. Which of the following findings
should the nurse expect?
a. Generalized edema
b. Elevated urine specific
gravity c. Thready pulse
d. Increased hematocrit
13. A nurse is assessing a client who has a chest tube following a thoracotomy. Which
of the following findings requires intervention by the nurse?
a. 1 cm of water present in the water seal chamber.
b. Tidaling with spontaneous respirations.
c. Suction chamber pressure of -20 cm H2O
d. Drainage collection chamber is 1/3 full.
14. A nurse is analyzing the laboratory data on a client who has dehydration. Which finding
should the nurse anticipate in a client who has fluid volume deficit?
a. Decreased serum osmolarity.
b. Decreased hematocrit.
c. Elevated blood urea nitrogen (BUN)
d. lower urine specific gravity
15. A nurse is performing a skin assessment on a client who has risk factors for development
of skincancer. The nurse should understand that a suspicious lesion is
a. Asymmetric, with variegated coloring
b. Scaly and red.
c. Brown, with a wart-like texture.
d. Firm and rubbery