100 ITEM COMPREHENSIVE NURSING EXAM
WITH ANSWERS
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 - CORRECT ANSWER - 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 breath and cough
D) Monitor oxygen saturation - CORRECT ANSWER - 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 assigned to this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
D) Severe multiple trauma - CORRECT ANSWER - 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 posttests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration - CORRECT ANSWER - 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 - CORRECT ANSWER - 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 - CORRECT
ANSWER - 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 tellsthe
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 - CORRECT ANSWER - 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 - CORRECT ANSWER - Thterm-1e 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
takingchlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramine
C) Foods fermented with yeast
D) Canned citrus fruit drinks - CORRECT ANSWER - 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." - CORRECT ANSWER - 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 - CORRECT ANSWER - 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 - CORRECT ANSWER - 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
WITH ANSWERS
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 - CORRECT ANSWER - 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 breath and cough
D) Monitor oxygen saturation - CORRECT ANSWER - 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 assigned to this nurse is which child?
A) Congenital cardiac defects
B) An acute febrile illness
C) Prolonged hypoxemia
D) Severe multiple trauma - CORRECT ANSWER - 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 posttests
B) Ask questions during practice
C) Allow another diabetic to assist
D) Observe a return demonstration - CORRECT ANSWER - 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 - CORRECT ANSWER - 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 - CORRECT
ANSWER - 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 tellsthe
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 - CORRECT ANSWER - 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 - CORRECT ANSWER - Thterm-1e 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
takingchlorpromazine HCL (Thorazine)?
A) Direct sunlight
B) Foods containing tyramine
C) Foods fermented with yeast
D) Canned citrus fruit drinks - CORRECT ANSWER - 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." - CORRECT ANSWER - 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 - CORRECT ANSWER - 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 - CORRECT ANSWER - 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
