Comp predictor B
Study online at https://quizlet.com/_e3o2u8
1. A nurse is preparing to replace a patient's transdermal fentanyl patch after 72
hours of use. After opening the packet with the new pouch, the patient refuses
to accept it. Which action should the nurse take?
A) Withhold pain medications for 24 hr after the old patch is removed.
B) Ask another nurse to witness the disposal of the new patch.
C) Seal the patches in a plastic bag and place in the client's trash basket.
D) Stick the two patches to each other and place them in the sharps bin.: B) Ask
another nurse to witness the disposal of the new patch.
2. A nurse is caring for a client with a PE. The client is receiving heparin IV at
1,200 units/hr and warfarin 5 mg PO daily. The morning lab values are aPTT 98
seconds and INR 1.8. Which action should the nurse take?
A) Prepare to administer vitamin K1.
B) Prepare to administer alteplase.
C) Withhold the heparin infusion.
D) Withhold the next dose of warfarin.: C) Withhold the heparin infusion.
The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2,
making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage
should be reduced or the infusion withheld until the aPTT returns to the therapeutic range.
3. A nurse at an urgent care clinic is assessing a patient with impaired vision in 1
eye. Which report from the patient should indicate to the nurse that the client
has a detached retina?
A) Halos around lights
B) Floating dark spots
C) Pain in the affected eye
D) Cloudy vision: B) Floating dark spots
4. A nurse is assessing an infant with hydrocephalus and is 6 hours post-op
following placement of a VP shunt. Which finding should the nurse report to
the provider?
A) Heart rate 122/min
B) Irritability when being held
, Comp predictor B
Study online at https://quizlet.com/_e3o2u8
C) Hypoactive bowel sounds
D) Urine specific gravity 1.018: B) Irritability when being held
5. A nurse is assessing a newborn's HR. Which action should the nurse take?
A) Assess the apical pulse while the newborn is crying to detect cardiac prob-
lems.
B) Palpate the radial pulse and determine the rate based on number of beats
per minute.
C) Listen to the apical pulse while palpating the radial pulse to detect variance.
D) Auscultate the apical pulse and count beats for at least 1 min.: D) Auscultate the
apical pulse and count beats for at least 1 min.
6. A nurse is caring for a client with a fecal impaction. Which action should the
nurse take when digitally evacuating the stool?
A) Place the client in the lithotomy position.
B) Elicit a vagal response by performing gentle rectal stimulation.
C) Administer oral bisacodyl 30 min prior to the procedure.
D) Insert a lubricated gloved finger and advance along the rectal wall.: D) Insert a
lubricated gloved finger and advance along the rectal wall.
7. A nurse is providing dietary teaching to a patient taking phenelzine. Which
food recommendations should the nurse make? (Select all)
A) Broccoli
B) Yogurt
C) Pepperoni pizza
D) Cream cheese
E) Bologna sandwich: A) Broccoli
B) Yogurt
D) Cream cheese
8. A nurse administers an incorrect dose of a med to a client. The nurse rec-
ognizes the error immediately and completes an incident report. Which fact
related to the incident should the nurse document in the client's medical
record?
A) Completion of the incident report
B) Time the medication was given
, Comp predictor B
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C) Reason for the medication error
D) Notification of the pharmacist: B) Time the medication was given
9. A nurse on a pediatric unit received report on 4 children. Which child should
the nurse assess first?
A) A 6-month-old infant who has croup and an O2 saturation of 92% on room
air
B) A 15-year-old adolescent who is 2 hr postoperative following an open reduc-
tion and internal fixation of the left ankle and is requesting pain medication
C) A 3-year-old toddler who has gastroenteritis, moderate dehydration, and
had two loose bowel movements over the past 24 hr
D) A 10-year-old child who is awaiting surgery for an appendectomy and expe-
rienced sudden relief from pain: D) A 10-year-old child who is awaiting surgery for an appendectomy
and experienced sudden relief from pain
Using the urgent vs. non-urgent approach to client care, the nurse should determine that the client to assess first is the
child awaiting an appendectomy who suddenly experiences pain relief as this can be an indication of peritonitis from
a ruptured appendix.
10. A community health nurse is providing teaching about home safety with a
group of elderly clients. Which statement should the nurse make?
A) "Unplug your appliances by grasping the cord and pulling it straight from
the outlet."
B) "Set your water heater temperature at 130 degrees Fahrenheit."
C) "Use throw rugs in high-traffic areas to partially cover wood floors."
D) "Have grab bars installed around your bathtub and toilet.": D) "Have grab bars
installed around your bathtub and toilet."
11. A nurse in the ED is assessing a school-age child who was brought in by
her parents and has scald burns to both hands and wrists. The nurse suspects
physical abuse. Which action should the nurse take?
A) Discuss his suspicion of physical abuse with the provider.
B) Confront the parents with his suspicion of physical abuse.
C) Ask the hospital security to detain and question the parents.
D) Contact child protective services.: D) Contact child protective services.
, Comp predictor B
Study online at https://quizlet.com/_e3o2u8
12. A nurse is caring for a patient with acute blood loss following a trauma. The
patient refuses a blood transfusion that could save his life. Which action should
the nurse take first?
A) Document the client's refusal in the medical record.
B) Honor the client's decision to refuse the blood transfusion.
C) Explore the client's reasons for refusing the treatment.
D) Discuss the client's refusal with the provider.: C) Explore the client's reasons for refusing the
treatment.
13. A nurse is teaching a client at 20 weeks gestation about common prenatal
discomfort. Which statement by the client indicates an understanding of the
teaching?
A) "I will decrease my intake of high-fiber foods."
B) "I will apply an anti-inflammatory ointment if I develop a rash on my face."
C) "I will sleep flat on my back if I develop back pain."
D) "I will wear a supportive bra overnight.": D) "I will wear a supportive bra overnight."
14. A nurse is providing discharge education to a patient who is to receive home
oxygen therapy. Which instruction should the nurse include in the teaching?
A) Check the functioning of oxygen equipment once each week.
B) Wear clothing made with cotton fabrics while oxygen is in use.
C) Apply petroleum-based lubricant to the nares as needed.
D) Store full oxygen tanks on their side.: B) Wear clothing made with cotton fabrics while oxygen
is in use.
The nurse should teach the client to apply a water-soluble lubricant to soothe irritation of the mucous membranes,
because products containing oils are flammable when near oxygen.
15. A nurse manager is preparing an education session about advocacy to a
group of nurses. The nurse manager should include what information in the
teaching?
A) Advocacy is a leadership role that helps others to self-actualize.
B) Subordinates are an advocate for the nurse manager.
C) Advocacy is to encourage client dependence in decision making.
D) Nurse managers should distrust people who speak out about harmful or
Study online at https://quizlet.com/_e3o2u8
1. A nurse is preparing to replace a patient's transdermal fentanyl patch after 72
hours of use. After opening the packet with the new pouch, the patient refuses
to accept it. Which action should the nurse take?
A) Withhold pain medications for 24 hr after the old patch is removed.
B) Ask another nurse to witness the disposal of the new patch.
C) Seal the patches in a plastic bag and place in the client's trash basket.
D) Stick the two patches to each other and place them in the sharps bin.: B) Ask
another nurse to witness the disposal of the new patch.
2. A nurse is caring for a client with a PE. The client is receiving heparin IV at
1,200 units/hr and warfarin 5 mg PO daily. The morning lab values are aPTT 98
seconds and INR 1.8. Which action should the nurse take?
A) Prepare to administer vitamin K1.
B) Prepare to administer alteplase.
C) Withhold the heparin infusion.
D) Withhold the next dose of warfarin.: C) Withhold the heparin infusion.
The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2,
making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage
should be reduced or the infusion withheld until the aPTT returns to the therapeutic range.
3. A nurse at an urgent care clinic is assessing a patient with impaired vision in 1
eye. Which report from the patient should indicate to the nurse that the client
has a detached retina?
A) Halos around lights
B) Floating dark spots
C) Pain in the affected eye
D) Cloudy vision: B) Floating dark spots
4. A nurse is assessing an infant with hydrocephalus and is 6 hours post-op
following placement of a VP shunt. Which finding should the nurse report to
the provider?
A) Heart rate 122/min
B) Irritability when being held
, Comp predictor B
Study online at https://quizlet.com/_e3o2u8
C) Hypoactive bowel sounds
D) Urine specific gravity 1.018: B) Irritability when being held
5. A nurse is assessing a newborn's HR. Which action should the nurse take?
A) Assess the apical pulse while the newborn is crying to detect cardiac prob-
lems.
B) Palpate the radial pulse and determine the rate based on number of beats
per minute.
C) Listen to the apical pulse while palpating the radial pulse to detect variance.
D) Auscultate the apical pulse and count beats for at least 1 min.: D) Auscultate the
apical pulse and count beats for at least 1 min.
6. A nurse is caring for a client with a fecal impaction. Which action should the
nurse take when digitally evacuating the stool?
A) Place the client in the lithotomy position.
B) Elicit a vagal response by performing gentle rectal stimulation.
C) Administer oral bisacodyl 30 min prior to the procedure.
D) Insert a lubricated gloved finger and advance along the rectal wall.: D) Insert a
lubricated gloved finger and advance along the rectal wall.
7. A nurse is providing dietary teaching to a patient taking phenelzine. Which
food recommendations should the nurse make? (Select all)
A) Broccoli
B) Yogurt
C) Pepperoni pizza
D) Cream cheese
E) Bologna sandwich: A) Broccoli
B) Yogurt
D) Cream cheese
8. A nurse administers an incorrect dose of a med to a client. The nurse rec-
ognizes the error immediately and completes an incident report. Which fact
related to the incident should the nurse document in the client's medical
record?
A) Completion of the incident report
B) Time the medication was given
, Comp predictor B
Study online at https://quizlet.com/_e3o2u8
C) Reason for the medication error
D) Notification of the pharmacist: B) Time the medication was given
9. A nurse on a pediatric unit received report on 4 children. Which child should
the nurse assess first?
A) A 6-month-old infant who has croup and an O2 saturation of 92% on room
air
B) A 15-year-old adolescent who is 2 hr postoperative following an open reduc-
tion and internal fixation of the left ankle and is requesting pain medication
C) A 3-year-old toddler who has gastroenteritis, moderate dehydration, and
had two loose bowel movements over the past 24 hr
D) A 10-year-old child who is awaiting surgery for an appendectomy and expe-
rienced sudden relief from pain: D) A 10-year-old child who is awaiting surgery for an appendectomy
and experienced sudden relief from pain
Using the urgent vs. non-urgent approach to client care, the nurse should determine that the client to assess first is the
child awaiting an appendectomy who suddenly experiences pain relief as this can be an indication of peritonitis from
a ruptured appendix.
10. A community health nurse is providing teaching about home safety with a
group of elderly clients. Which statement should the nurse make?
A) "Unplug your appliances by grasping the cord and pulling it straight from
the outlet."
B) "Set your water heater temperature at 130 degrees Fahrenheit."
C) "Use throw rugs in high-traffic areas to partially cover wood floors."
D) "Have grab bars installed around your bathtub and toilet.": D) "Have grab bars
installed around your bathtub and toilet."
11. A nurse in the ED is assessing a school-age child who was brought in by
her parents and has scald burns to both hands and wrists. The nurse suspects
physical abuse. Which action should the nurse take?
A) Discuss his suspicion of physical abuse with the provider.
B) Confront the parents with his suspicion of physical abuse.
C) Ask the hospital security to detain and question the parents.
D) Contact child protective services.: D) Contact child protective services.
, Comp predictor B
Study online at https://quizlet.com/_e3o2u8
12. A nurse is caring for a patient with acute blood loss following a trauma. The
patient refuses a blood transfusion that could save his life. Which action should
the nurse take first?
A) Document the client's refusal in the medical record.
B) Honor the client's decision to refuse the blood transfusion.
C) Explore the client's reasons for refusing the treatment.
D) Discuss the client's refusal with the provider.: C) Explore the client's reasons for refusing the
treatment.
13. A nurse is teaching a client at 20 weeks gestation about common prenatal
discomfort. Which statement by the client indicates an understanding of the
teaching?
A) "I will decrease my intake of high-fiber foods."
B) "I will apply an anti-inflammatory ointment if I develop a rash on my face."
C) "I will sleep flat on my back if I develop back pain."
D) "I will wear a supportive bra overnight.": D) "I will wear a supportive bra overnight."
14. A nurse is providing discharge education to a patient who is to receive home
oxygen therapy. Which instruction should the nurse include in the teaching?
A) Check the functioning of oxygen equipment once each week.
B) Wear clothing made with cotton fabrics while oxygen is in use.
C) Apply petroleum-based lubricant to the nares as needed.
D) Store full oxygen tanks on their side.: B) Wear clothing made with cotton fabrics while oxygen
is in use.
The nurse should teach the client to apply a water-soluble lubricant to soothe irritation of the mucous membranes,
because products containing oils are flammable when near oxygen.
15. A nurse manager is preparing an education session about advocacy to a
group of nurses. The nurse manager should include what information in the
teaching?
A) Advocacy is a leadership role that helps others to self-actualize.
B) Subordinates are an advocate for the nurse manager.
C) Advocacy is to encourage client dependence in decision making.
D) Nurse managers should distrust people who speak out about harmful or
