100 item Comprehensive Exam with Answers and Rationale .
1. The nurse enters the room as a 3 year-old is having a generalized seizure. Which
intervention should the nurse do first?
A) Clear the area of any hazards
B) Place the child on the side
C) Restrain the child
D) Give the prescribed anticonvulsant
The correct answer is B: Place the child on the side
Protecting the airway is the top priority in a seizure. If a child is actively convulsing, a patent
airway and oxygenation must be assured.
2. A client has just returned to the medical-surgical unit following a segmental lung
resection. After assessing the client, the first nursing action would be to
A) Administer pain medication
B) Suction excessive tracheobronchial secretions
C) Assist client to turn, deep breathe and cought
D) Monitor oxygen saturation
The correct answer is B: Suction excessive tracheobronchial secretions
Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients
maintains an open airway which is always the priority nursing intervention.
3. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse
should recognize that the child at highest risk for cardiac arrest and is the least likely to be
assiged to this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
D) Severe multiple trauma
The correct answer is C: Prolonged hypoxemia
Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia.
Children usually have both cardiac and respiratory arrest.
4. Which of the following would be the best strategy for the nurse to use when teaching
insulin injection techniques to a newly diagnosed client with diabetes?
A) Give written pre and post tests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration
The correct answer is D: Observe a return demonstration
Since this is a psychomotor skill, this is the best way to know if the client has learned the
proper technique.
5. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart
disease. Which of these is most likely to be seen with this diagnosis?
A) Several otitis media episodes in the last year
B) Weight and height in 10th percentile since birth
C) Takes frequent rest periods while playing
D) Changing food preferences and dislikes
The correct answer is C: Takes frequent rest periods while playing
Children with heart disease tend to have exercise intolerance. The child self-limits activity,
which is consistent with manifestations of congenital heart disease in children.
6. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which
of these cases of childhood poisoning would the nurse suggest that parents have the child
drink orange juice?
,A) An 18 month-old who ate an undetermined amount of crystal drain cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of
diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain
cleaner. Drain cleaner is very alkaline. The orange juice is acidic and will help to neutralize
this substance.
7. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse
that she has everything ready for the baby and has made plans for the first weeks together
at home. Which normal emotional reaction does the nurse recognize?
A) Acceptance of the pregnancy
B) Focus on fetal development
C) Anticipation of the birth
D) Ambivalence about pregnancy
The correct answer is C: Anticipation of the birth
Directing activities toward preparation for the newborn''s needs and personal adjustment
are indicators of appropriate emotional response in the third trimester.
8. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have
chalky white-to-yellowish staining with pitting of the enamel. Which of the following
conditions would most likely explain these findings?
A) Ingestion of tetracycline
B) Excessive fluoride intake
C) Oral iron therapy
D) Poor dental hygiene
The correct answer is B: Excessive fluoride intake
The described findings are indicative of fluorosis, a condition characterized by an increase in
the extent and degree of the enamel''s porosity. This problem can be associated with
repeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride.
9. Which of the following should the nurse teach the client to avoid when taking
chlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramine
C) Foods fermented with yeast
D) Canned citrus fruit drinks
The correct answer is A: Avoid direct sunlight
Phenothiazine increases sensitivity to the sun, making clients especially susceptible to
sunburn.
10. The nurse is discussing dietary intake with an adolescent who has acne. The most
appropriate statement for the nurse is
A) "Eat a balanced diet for your age."
B) "Increase your intake of protein and Vitamin A."
C) "Decrease fatty foods from your diet."
D) "Do not use caffeine in any form, including chocolate."
The correct answer is A: "Eat a balanced diet for your age."
A diet for a teenager with acne should be a well balanced diet for their age. There are no
recommended additions and subtractions from the diet.
11. The nurse is caring for a child who has just returned from surgery following a
tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
A) Offer ice cream every 2 hours
B) Place the child in a supine position
C) Allow the child to drink through a straw
, D) Observe swallowing patterns
The correct answer is D: Observe swallowing patterns
The nurse should observe for increased swallowing frequency to check for hemorrhage.
12. The nurse is caring for a client with acute pancreatitis. After pain management, which
intervention should be included in the plan of care?
A) Cough and deep breathe every 2 hours
B) Place the client in contact isolation
C) Provide a diet high in protein
D) Institute seizure precautions
The correct answer is A: Cough and deep breathe every 2 hours
Respiratory infections are common because of fluid in the retro peritoneum pushing up
against the diaphragm causing shallow respirations. Encouraging the client to cough and
deep breathe every 2 hours will diminish the occurrence of this complication.
13. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist the
client with nutrition needs, the nurse should
A) Offer small meals of high calorie soft food
B) Assist the client to sit in a chair for meals
C) Provide additional servings of fruits and raw vegetables
D) Encourage the client to eat fish, liver and chicken
The correct answer is A: Offer small meals of high calorie soft food
If the client is losing weight because of poor appetite due to the pain, assist in selecting
foods that are high in calories and nutrients, to provide more nourishment with less chewing.
Suggest that frequent, small meals be eaten instead of three large ones. To minimize jaw
movements when eating, suggest that foods be pureed.
14. A client treated for depression tells the nurse at the mental health clinic that he recently
purchased a handgun because he is thinking about suicide. The first nursing action should
be to
A) Notify the health care provider immediately
B) Suggest in-patient psychiatric care
C) Respect the client's confidential disclosure
D) Phone the family to warn them of the risk
The correct answer is A: Notify the health care provider immediately
The health care provider must be contacted immediately as the client is a danger to self and
others. Hospitalization is indicated.
15. The initial response by the nurse to a delusional client who refuses to eat because of a
belief that the food is poisoned is
A) "You think that someone wants to poison you?"
B) "Why do you think the food is poisoned?"
C) "These feelings are a symptom of your illness."
D) "You’re safe here. I won’t let anyone poison you."
The correct answer is A: "You think that someone wants to poison you?"
This response acknowledges perception through a reflective question which presents
opportunity for discussion, clarification of meaning, and expressing doubt.
16. A client has just been admitted with portal hypertension. Which nursing diagnosis would
be a priority in planning care?
A) Altered nutrition: less than body requirements
B) Potential complication hemorrhage
C) Ineffective individual coping
D) Fluid volume excess
The correct answer is B: Potential complication hemorrhage
Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk
1. The nurse enters the room as a 3 year-old is having a generalized seizure. Which
intervention should the nurse do first?
A) Clear the area of any hazards
B) Place the child on the side
C) Restrain the child
D) Give the prescribed anticonvulsant
The correct answer is B: Place the child on the side
Protecting the airway is the top priority in a seizure. If a child is actively convulsing, a patent
airway and oxygenation must be assured.
2. A client has just returned to the medical-surgical unit following a segmental lung
resection. After assessing the client, the first nursing action would be to
A) Administer pain medication
B) Suction excessive tracheobronchial secretions
C) Assist client to turn, deep breathe and cought
D) Monitor oxygen saturation
The correct answer is B: Suction excessive tracheobronchial secretions
Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients
maintains an open airway which is always the priority nursing intervention.
3. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse
should recognize that the child at highest risk for cardiac arrest and is the least likely to be
assiged to this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
D) Severe multiple trauma
The correct answer is C: Prolonged hypoxemia
Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia.
Children usually have both cardiac and respiratory arrest.
4. Which of the following would be the best strategy for the nurse to use when teaching
insulin injection techniques to a newly diagnosed client with diabetes?
A) Give written pre and post tests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration
The correct answer is D: Observe a return demonstration
Since this is a psychomotor skill, this is the best way to know if the client has learned the
proper technique.
5. The nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart
disease. Which of these is most likely to be seen with this diagnosis?
A) Several otitis media episodes in the last year
B) Weight and height in 10th percentile since birth
C) Takes frequent rest periods while playing
D) Changing food preferences and dislikes
The correct answer is C: Takes frequent rest periods while playing
Children with heart disease tend to have exercise intolerance. The child self-limits activity,
which is consistent with manifestations of congenital heart disease in children.
6. The nurse is reassigned to work at the Poison Control Center telephone hotline. In which
of these cases of childhood poisoning would the nurse suggest that parents have the child
drink orange juice?
,A) An 18 month-old who ate an undetermined amount of crystal drain cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of
diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
The correct answer is A: An 18 month-old who ate an undetermined amount of crystal drain
cleaner. Drain cleaner is very alkaline. The orange juice is acidic and will help to neutralize
this substance.
7. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse
that she has everything ready for the baby and has made plans for the first weeks together
at home. Which normal emotional reaction does the nurse recognize?
A) Acceptance of the pregnancy
B) Focus on fetal development
C) Anticipation of the birth
D) Ambivalence about pregnancy
The correct answer is C: Anticipation of the birth
Directing activities toward preparation for the newborn''s needs and personal adjustment
are indicators of appropriate emotional response in the third trimester.
8. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have
chalky white-to-yellowish staining with pitting of the enamel. Which of the following
conditions would most likely explain these findings?
A) Ingestion of tetracycline
B) Excessive fluoride intake
C) Oral iron therapy
D) Poor dental hygiene
The correct answer is B: Excessive fluoride intake
The described findings are indicative of fluorosis, a condition characterized by an increase in
the extent and degree of the enamel''s porosity. This problem can be associated with
repeated swallowing of toothpaste with fluoride or drinking water with high levels of fluoride.
9. Which of the following should the nurse teach the client to avoid when taking
chlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramine
C) Foods fermented with yeast
D) Canned citrus fruit drinks
The correct answer is A: Avoid direct sunlight
Phenothiazine increases sensitivity to the sun, making clients especially susceptible to
sunburn.
10. The nurse is discussing dietary intake with an adolescent who has acne. The most
appropriate statement for the nurse is
A) "Eat a balanced diet for your age."
B) "Increase your intake of protein and Vitamin A."
C) "Decrease fatty foods from your diet."
D) "Do not use caffeine in any form, including chocolate."
The correct answer is A: "Eat a balanced diet for your age."
A diet for a teenager with acne should be a well balanced diet for their age. There are no
recommended additions and subtractions from the diet.
11. The nurse is caring for a child who has just returned from surgery following a
tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
A) Offer ice cream every 2 hours
B) Place the child in a supine position
C) Allow the child to drink through a straw
, D) Observe swallowing patterns
The correct answer is D: Observe swallowing patterns
The nurse should observe for increased swallowing frequency to check for hemorrhage.
12. The nurse is caring for a client with acute pancreatitis. After pain management, which
intervention should be included in the plan of care?
A) Cough and deep breathe every 2 hours
B) Place the client in contact isolation
C) Provide a diet high in protein
D) Institute seizure precautions
The correct answer is A: Cough and deep breathe every 2 hours
Respiratory infections are common because of fluid in the retro peritoneum pushing up
against the diaphragm causing shallow respirations. Encouraging the client to cough and
deep breathe every 2 hours will diminish the occurrence of this complication.
13. The nurse is caring for a client with trigeminal neuralgia (tic douloureaux). To assist the
client with nutrition needs, the nurse should
A) Offer small meals of high calorie soft food
B) Assist the client to sit in a chair for meals
C) Provide additional servings of fruits and raw vegetables
D) Encourage the client to eat fish, liver and chicken
The correct answer is A: Offer small meals of high calorie soft food
If the client is losing weight because of poor appetite due to the pain, assist in selecting
foods that are high in calories and nutrients, to provide more nourishment with less chewing.
Suggest that frequent, small meals be eaten instead of three large ones. To minimize jaw
movements when eating, suggest that foods be pureed.
14. A client treated for depression tells the nurse at the mental health clinic that he recently
purchased a handgun because he is thinking about suicide. The first nursing action should
be to
A) Notify the health care provider immediately
B) Suggest in-patient psychiatric care
C) Respect the client's confidential disclosure
D) Phone the family to warn them of the risk
The correct answer is A: Notify the health care provider immediately
The health care provider must be contacted immediately as the client is a danger to self and
others. Hospitalization is indicated.
15. The initial response by the nurse to a delusional client who refuses to eat because of a
belief that the food is poisoned is
A) "You think that someone wants to poison you?"
B) "Why do you think the food is poisoned?"
C) "These feelings are a symptom of your illness."
D) "You’re safe here. I won’t let anyone poison you."
The correct answer is A: "You think that someone wants to poison you?"
This response acknowledges perception through a reflective question which presents
opportunity for discussion, clarification of meaning, and expressing doubt.
16. A client has just been admitted with portal hypertension. Which nursing diagnosis would
be a priority in planning care?
A) Altered nutrition: less than body requirements
B) Potential complication hemorrhage
C) Ineffective individual coping
D) Fluid volume excess
The correct answer is B: Potential complication hemorrhage
Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk
