COMPLETE GUIDE 2023/2024 A+
Comprehensive Practice A
**A client is postoperative following a lumbar discectomy and is having difficulty voiding.
Thenurse should recognize that which of the following medications place the client at risk for
urinary retention?
Ketorolac
Hydromorphone
(Dilaudid) Bethanechol
(Urecholine)
Tobramycin (Nebcin)
**A nurse is caring for an older adult client in a long-term care facility who is disoriented and
continues to get out of bed without assistance. Which of the following images indicates the
nurse is using an appropriate intervention to minimize the risk of injury due to a fall?
D
**A practical nurse (PN) on medical-surgical unit is beginning her shift and is working with
aregistered nurse (RN) and an assistive personnel (AP). The PN should expect to be assigned
which of the following tasks?
Teach a client who has a new diagnosis of diabetes mellitus how to self-administer insulin.
Create a plan of care for a newly admitted client.
Obtain a stool specimen from a client who has ulcerative colitis----
Administer an NG tube feeding to a client who had a stroke
**A nurse on an acute mental health unit observes a client who begins to speak loudly in the
common room, saying that he can’t hear the TV. Which of the following is an appropriate
response by the nurse?
You will need to go to your room until you can calm down
okayThe TV is loud enough for everyone to hear it
,You are being inconsiderate. Please stop talking so
loudly Let’s go to another room to talk about what is
upsetting you
**A client tells a nurse that he would like to observe kosher dietary laws. The nurse
shouldrecognize which of the following?
A vegetarian diet is the preferred diet
Dairy products are served separately from meat
Fasting during daylight is required during a month-long
holidayFish with scales and fins should not be eaten
**A nursing unit receives new glucose monitoring equipment from staff development with the
promise that in-service education will be given soon. Which of the following instructions
shouldthe nurse give to the assistive personnel (AP) who is preforming glucose monitoring on
the unit?
Contact the staff development department for
instruction
Continue using the current glucose monitors
Check for accuracy and proper functioning of the new monitor
Read the instruction manual before attempting to use the new monitor
**Which of the following should the nurse document as an indication of the IV infiltration in a
client’s forearm?
Redness along vein
Tissue sloughing at the site
Forearm that is warm to the touch
Pallor surrounding the infusion site
,**A client requests information about advanced directives. Which of the following is
theappropriate response by the nurse?
Advanced directives are written instructions regarding end of life care
Advanced directives provide education on palliative care issues
Advanced directives require the provider’s approval before changes can be implemented
Advanced directives help determine legal competency
**A nurse is caring for a client who is on telemetry. Which of the following ECG findings
shouldthe nurse report to the charge nurse?
One P wave prior to each QRS complex
PR interval 0.24 seconds
QRS duration 0.06
secondsVentricular rate
75/min
**A nurse is checking the reflexes of a newborn. Which of the following techniques should
thenurse use to elicit the Babinski reflex?
Startle the infant by clapping hands
Stroke the sole of the infant’s foot upward and toward the great toe
Hold the infant upright and allow one foot to touch the table’s
surfacePlace an object in the palm of the infant’s hand
**A charge nurse in a long-term care facility notices an assistive personnel’s (AP) repeated
failure to provide oral care for clients. Which of the following actions should the nurse take?
Provide oral care for clients after the AP has completed other care
Develop an educational session about the importance of oral care for all
Aps
Discuss the unacceptable behavior with the AP while reinforcing expectations
, Suspend the AP for 3 days pending disciplinary action
**A nurse is caring for a client who has terminal cancer. Which of the following statements
bythe client’s family should indicate the nurse that they are coping with their situation?
Dad I remember the time we all went to the lake fishing
Dad I truly believe that it’s not your time to leave us
I feel like I don’t know what to do anymore
I think we need to concentrate on whose house we plan to meet at for our holiday get-together
**A nurse is performing a dressing change for a client who had abdominal surgery 5 days
ago. The nurse notes organs protruding from the incision. Which of the following actions
should thenurse take?
Apply an abdominal binder
Have the client lie flat in bed.
Cover the exposed area with sterile, saline-soaked dressing
Place gentle pressure on the exposed organ with sterile
gauze
**A nurse in a skilled nursing facility is caring for a client who is receiving warfarin
(Coumadin) therapy following a total hip replacement. An assistive personnel reports a positive
guaiac.
Which of the following laboratory values should the nurse report to the
provider?Hematocrit 40%
International normalized ratio of 4.5
Hemoglobin 15 g/dL--
Prothrombin time 18 seconds
** A nurse is reinforcing teaching with a client who has hypertension and is
beginning medication therapy with captopril (Capoten). Which of the following
over-the-countermedications should the nurse instruct the client to avoid?