COMPREHENSIVE PN ASSESSMENT A QUESTIONS
AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
A nurse is caring for a patient who is scheduled for a mastectomy the following day. The
patient is tearful and tells the nurse that they are not ready to have this procedure done
at this time. Which of the following responses should the nurse make?
• "Why didn't you share this when the surgeon was here?"
• "There is no need to worry. The surgeon will take good care of you."
• "Would you like for me to talk to the surgeon with you?"
• "You are just anxious right now. It is normal to feel this way."
*The nurse should advocate for the patient's needs by offering to talk to the surgeon with
the patient. The nurse should also offer moral support and encourage the patient to
express their concerns and make a more informed decision.
A nurse is documenting patient care in the medical record. Which of the following entries
should the nurse make?
• "patient received MS 1 mg IM for pain at 1300."
• "patient remains NPO until x-ray procedure is complete."
• "patient provided cheese and crackers for his snack."
• "patient reports experiencing nausea & vomiting."
The nurse should advocate for the patient's needs by offering to talk to the surgeon with
the patient. The nurse should also offer moral support and encourage the patient to
express their concerns and make a more informed decision.
*The nurse should use documentation that is specific and uses accepted terminology.
The nurse can use the abbreviation "NPO," which is an accepted abbreviation for
"nothing by mouth."
A nurse is reviewing various defense mechanisms with a newly licensed nurse. Which
of the following patient statements should the nurse use as an example of
rationalization?
• "I didn't get a good grade because my teacher does not like me."
• "I do not believe you because my mother cannot be gone."
• "When I've had a few drinks, I feel much better about myself."
• "I will call the doctor for my test results after I return from this vacation."
The nurse should use documentation that is specific and uses accepted terminology.
The nurse can use the abbreviation "NPO," which is an accepted abbreviation for
"nothing by mouth."
*The nurse should recognize this statement as the use of rationalization by a patient.
Rationalization is used as a means of justifying unreasonable feelings, thoughts, or
actions.
,A nurse is collecting data from a patient who reports recent methamphetamine use.
Which of the following manifestations should the nurse expect?
• Hypothermia
• Increased appetite
• Hypersomnia
• Dilated pupils Dilated pupils
*The nurse should expect a patient who has stimulant intoxication to have dilated pupils.
Other expected findings of stimulant intoxication include increased energy and
hypervigilance.
A nurse in an outpatient surgery center is reinforcing discharge teaching with a patient
following a lithotripsy for uric acid stones. which of the following instructions should the
nurse plan to include in the teaching?
• Limit fluid intake to 1 L per day.
• Report the appearance of blood in the urine.
• Strain the urine to collect stone fragments.
• Increase dietary protein intake.
Strain the urine to collect stone fragments.
*The patient should verify passage of the stones by straining their urine. Laboratory
analysis of the stones can provide information to help prevent future stone formation. A
nurse is monitoring a patient who is 12 hr postoperative following a cholecystectomy and
received morphine 30 min ago for pain. The nurse should identify which of the following
findings as an adverse effect of the medication?
• Diarrhea
• Respiratory rate 10/min
• Pulse rate 96/min
• Persistent cough Respiratory rate 10/min
*A respiratory rate of 10/min indicates respiratory depression, which is an adverse effect
of morphine.
A nurse is performing a dressing change for a patient who is 3 days postoperative.
Which of the following findings should the nurse report to the provider?
• Serosanguineous drainage on the old dressing
• Pink incision line with slight crusting
• Yellow-green drainage at the incision line
• Slight swelling around the staples Yellow-green drainage at the incision line
*Yellow-green, purulent, or odorous drainage indicates the wound is infected. The nurse
should report this finding to the provider.
,A nurse is caring for a patient who is receiving continuous feedings via a gastrostomy
tube. Which of the following actions should the nurse plan to take?
• Flush the tube with 60 mL of water after administering each of the patient's
medications.
• Flush the tube with 15 mL of water every 6 hr.
• Check for residual volume and then flush the tube with 100 mL of water.
• Flush the tube with 60 mL of water if it becomes clogged. Flush the tube with 60
mL of water if it becomes clogged
*The nurse should flush the feeding tube with 30 to 50 mL of warm water if the tube
becomes clogged to re-establish the patency of the gastrostomy tube.
A nurse is assisting with a discussion about STIs with a group of adolescents at a health
fair. Which of the following statements should the nurse make?
• "Men and women are at equal risk for acquiring STIs."
• "Females who have chlamydia are at increased risk for cervical cancer."
• "An infection with gonorrhea can result in infertility."
• "Human papillomavirus infections must be reported to the local health
department." "An infection with gonorrhea can result in infertility."
*Gonorrhea can lead to pelvic inflammatory disease and tubal scarring, which can result
in infertility in female patients.
A nurse is caring for a patient who has asthma and has been taking montelukast for 1
month. Which of the following findings should indicate to the nurse that the patient is
complying with this medication regimen?
• The patient takes the medication 15 min before exercising.
• The patient takes the medication once daily at bedtime.
• The patient states that they have been tapering off of the medication over the
past 2 weeks.
• The patient takes an extra dose of this medication when experiencing an asthma
attack.
The patient takes the medication once daily at bedtime.
*Montelukast, a leukotriene modifier, is taken once a day for maintenance at bedtime. A
nurse is monitoring a patient who is receiving IV fluids. For which of the following
findings should the nurse stop the infusion?
• Blood return at the hub of the catheter
• Absence of skin blanching
• Edema above the catheter insertion site
• Fluid leakage from the catheter connection Edema above the catheter insertion
site
, *Edema above the catheter site indicates infiltration. The nurse should stop the IV
infusion.
A nurs eis observing a patient who is the first stage of labor. Which of the following
interventions should the nurse recommend for this patient? (select all that apply)
• Squatting using an exercise ball
• Counterpressure to the sacral area
• Applying fundal pressure to the upper abdomen
• Pelvic rocking
• Supine positioning
• Squatting using an exercise ball
• Counterpressure to the sacral area
• Pelvic rocking
Squatting using an exercise ball can help relax the pelvis and perineal area and can
relieve pain during contractions.
Counterpressure to the sacral area can help decrease pain by relieving pressure on the
spinal nerves caused by the fetus's occiput.
Pelvic rocking can relieve backache during the first stage of labor. To perform this
motion, the patient hollows their back and then arches it to relieve back pain.
A nurse is caring for a patient who is in the final stages of cancer. Which of the following
patient situations should the nurse identify as an ethical dilemma?
• The patient is refusing to take any more medications or treatments.
• The patient asks the nurse to help them die peacefully in their sleep.
• The patient does not have advance directives in place.
• The patient tells the nurse they want to die at home.
The patient asks the nurse to help them die peacefully in their sleep.
*This situation presents an ethical issue for the nurse because the patient is asking for a
variation of active euthanasia, also known as assisted suicide, which is in violation of
the Code of Ethics for Nurses. The nurse is legally and ethically unable to support this
decision by the patient and should ask for assistance with this dilemma.
A nurse in an urgent care clinic is completing a patient examination. After listening to the
patient's lungs, which of the following adventitious sounds should the nurse document?
• Wheeze
• Fine crackles
• Stridor
• Friction rub Wheeze
*The nurse should document this sound as a wheeze. A wheeze is a high-pitched,
musical sound that is heard when air moves through a narrowed airway during either
inspiration or expiration.
A nurse is reinforcing teaching with a patient who is scheduled for a lumbar puncture.
Which of the following statements should the nurse make?
AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
A nurse is caring for a patient who is scheduled for a mastectomy the following day. The
patient is tearful and tells the nurse that they are not ready to have this procedure done
at this time. Which of the following responses should the nurse make?
• "Why didn't you share this when the surgeon was here?"
• "There is no need to worry. The surgeon will take good care of you."
• "Would you like for me to talk to the surgeon with you?"
• "You are just anxious right now. It is normal to feel this way."
*The nurse should advocate for the patient's needs by offering to talk to the surgeon with
the patient. The nurse should also offer moral support and encourage the patient to
express their concerns and make a more informed decision.
A nurse is documenting patient care in the medical record. Which of the following entries
should the nurse make?
• "patient received MS 1 mg IM for pain at 1300."
• "patient remains NPO until x-ray procedure is complete."
• "patient provided cheese and crackers for his snack."
• "patient reports experiencing nausea & vomiting."
The nurse should advocate for the patient's needs by offering to talk to the surgeon with
the patient. The nurse should also offer moral support and encourage the patient to
express their concerns and make a more informed decision.
*The nurse should use documentation that is specific and uses accepted terminology.
The nurse can use the abbreviation "NPO," which is an accepted abbreviation for
"nothing by mouth."
A nurse is reviewing various defense mechanisms with a newly licensed nurse. Which
of the following patient statements should the nurse use as an example of
rationalization?
• "I didn't get a good grade because my teacher does not like me."
• "I do not believe you because my mother cannot be gone."
• "When I've had a few drinks, I feel much better about myself."
• "I will call the doctor for my test results after I return from this vacation."
The nurse should use documentation that is specific and uses accepted terminology.
The nurse can use the abbreviation "NPO," which is an accepted abbreviation for
"nothing by mouth."
*The nurse should recognize this statement as the use of rationalization by a patient.
Rationalization is used as a means of justifying unreasonable feelings, thoughts, or
actions.
,A nurse is collecting data from a patient who reports recent methamphetamine use.
Which of the following manifestations should the nurse expect?
• Hypothermia
• Increased appetite
• Hypersomnia
• Dilated pupils Dilated pupils
*The nurse should expect a patient who has stimulant intoxication to have dilated pupils.
Other expected findings of stimulant intoxication include increased energy and
hypervigilance.
A nurse in an outpatient surgery center is reinforcing discharge teaching with a patient
following a lithotripsy for uric acid stones. which of the following instructions should the
nurse plan to include in the teaching?
• Limit fluid intake to 1 L per day.
• Report the appearance of blood in the urine.
• Strain the urine to collect stone fragments.
• Increase dietary protein intake.
Strain the urine to collect stone fragments.
*The patient should verify passage of the stones by straining their urine. Laboratory
analysis of the stones can provide information to help prevent future stone formation. A
nurse is monitoring a patient who is 12 hr postoperative following a cholecystectomy and
received morphine 30 min ago for pain. The nurse should identify which of the following
findings as an adverse effect of the medication?
• Diarrhea
• Respiratory rate 10/min
• Pulse rate 96/min
• Persistent cough Respiratory rate 10/min
*A respiratory rate of 10/min indicates respiratory depression, which is an adverse effect
of morphine.
A nurse is performing a dressing change for a patient who is 3 days postoperative.
Which of the following findings should the nurse report to the provider?
• Serosanguineous drainage on the old dressing
• Pink incision line with slight crusting
• Yellow-green drainage at the incision line
• Slight swelling around the staples Yellow-green drainage at the incision line
*Yellow-green, purulent, or odorous drainage indicates the wound is infected. The nurse
should report this finding to the provider.
,A nurse is caring for a patient who is receiving continuous feedings via a gastrostomy
tube. Which of the following actions should the nurse plan to take?
• Flush the tube with 60 mL of water after administering each of the patient's
medications.
• Flush the tube with 15 mL of water every 6 hr.
• Check for residual volume and then flush the tube with 100 mL of water.
• Flush the tube with 60 mL of water if it becomes clogged. Flush the tube with 60
mL of water if it becomes clogged
*The nurse should flush the feeding tube with 30 to 50 mL of warm water if the tube
becomes clogged to re-establish the patency of the gastrostomy tube.
A nurse is assisting with a discussion about STIs with a group of adolescents at a health
fair. Which of the following statements should the nurse make?
• "Men and women are at equal risk for acquiring STIs."
• "Females who have chlamydia are at increased risk for cervical cancer."
• "An infection with gonorrhea can result in infertility."
• "Human papillomavirus infections must be reported to the local health
department." "An infection with gonorrhea can result in infertility."
*Gonorrhea can lead to pelvic inflammatory disease and tubal scarring, which can result
in infertility in female patients.
A nurse is caring for a patient who has asthma and has been taking montelukast for 1
month. Which of the following findings should indicate to the nurse that the patient is
complying with this medication regimen?
• The patient takes the medication 15 min before exercising.
• The patient takes the medication once daily at bedtime.
• The patient states that they have been tapering off of the medication over the
past 2 weeks.
• The patient takes an extra dose of this medication when experiencing an asthma
attack.
The patient takes the medication once daily at bedtime.
*Montelukast, a leukotriene modifier, is taken once a day for maintenance at bedtime. A
nurse is monitoring a patient who is receiving IV fluids. For which of the following
findings should the nurse stop the infusion?
• Blood return at the hub of the catheter
• Absence of skin blanching
• Edema above the catheter insertion site
• Fluid leakage from the catheter connection Edema above the catheter insertion
site
, *Edema above the catheter site indicates infiltration. The nurse should stop the IV
infusion.
A nurs eis observing a patient who is the first stage of labor. Which of the following
interventions should the nurse recommend for this patient? (select all that apply)
• Squatting using an exercise ball
• Counterpressure to the sacral area
• Applying fundal pressure to the upper abdomen
• Pelvic rocking
• Supine positioning
• Squatting using an exercise ball
• Counterpressure to the sacral area
• Pelvic rocking
Squatting using an exercise ball can help relax the pelvis and perineal area and can
relieve pain during contractions.
Counterpressure to the sacral area can help decrease pain by relieving pressure on the
spinal nerves caused by the fetus's occiput.
Pelvic rocking can relieve backache during the first stage of labor. To perform this
motion, the patient hollows their back and then arches it to relieve back pain.
A nurse is caring for a patient who is in the final stages of cancer. Which of the following
patient situations should the nurse identify as an ethical dilemma?
• The patient is refusing to take any more medications or treatments.
• The patient asks the nurse to help them die peacefully in their sleep.
• The patient does not have advance directives in place.
• The patient tells the nurse they want to die at home.
The patient asks the nurse to help them die peacefully in their sleep.
*This situation presents an ethical issue for the nurse because the patient is asking for a
variation of active euthanasia, also known as assisted suicide, which is in violation of
the Code of Ethics for Nurses. The nurse is legally and ethically unable to support this
decision by the patient and should ask for assistance with this dilemma.
A nurse in an urgent care clinic is completing a patient examination. After listening to the
patient's lungs, which of the following adventitious sounds should the nurse document?
• Wheeze
• Fine crackles
• Stridor
• Friction rub Wheeze
*The nurse should document this sound as a wheeze. A wheeze is a high-pitched,
musical sound that is heard when air moves through a narrowed airway during either
inspiration or expiration.
A nurse is reinforcing teaching with a patient who is scheduled for a lumbar puncture.
Which of the following statements should the nurse make?
