Proctored Comprehensive Assessment
2024/2025 ,2026 Test Bank | Forms A &
B | Verified Real Exam Questions,
Answers, and Rationales | Graded A
Q1. A home health nurse is conducting an initial home visit for a client who has
terminal breast cancer. The client has two school-age children and a limited
support system. Which of the following is the priority nursing action?
• A. Inform the client of available community resources
• B. Assist the client in finding child care options
• C. Agree upon short-term goals for the client
• D. Ask the client about their understanding of the diagnosis
Correct Answer: A. Inform the client of available community resources
Rationale: The priority is to support the client with resources that will be most
helpful in managing their care, particularly given the limited support system.
Community resources can assist with caregiving, emotional support, and financial
aid .
Q2. A nurse is planning care for a client who is experiencing acute mania.
Which of the following actions should the nurse include in the plan of care?
, • A. Provide a flexible activity schedule
• B. Provide high-calorie nutritional supplements
• C. Allow the client to eat meals alone in her room
• D. Allow the client to choose her clothes independently
Correct Answer: B. Provide high-calorie nutritional supplements
Rationale: Clients with acute mania are often too hyperactive or distracted to eat
adequately, leading to weight loss and dehydration. High-calorie, high-protein
nutritional supplements and finger foods that can be eaten on the go should be
provided. A structured (not flexible) schedule, supervision during meals, and
assistance with clothing choices (to avoid inappropriate dress) are recommended .
Q3. A nurse is reviewing the medical records of four clients. Which of the
following prescriptions correct documentation?
• A. Atropine .4 mg IV stat
• B. Lorazapam 1.0 mg IV PRN every 6 hr
• C. Sucralfate 1 g PO hr ac
• D. Enoxaparin 30 mg SC every 12 hr
Correct Answer: D. Enoxaparin 30 mg SC every 12 hr
Rationale: The correct prescription is complete, correctly spelled, uses standard
abbreviations (SC for subcutaneous), and includes dose, route, and frequency. A
leading zero should be used for decimals less than 1 (0.4 mg, not .4 mg) .
,Q4. A nurse is performing a dressing change for a client who has a sacral
wound using negative pressure wound therapy. Which of the following actions
should the nurse take first?
• A. Determine the client's pain level
• B. Irrigate the wound with 0.9% sodium chloride irrigation
• C. Apply skin preparation to wound edges
• D. Don sterile gloves
Correct Answer: A. Determine the client's pain level
Rationale: According to the nursing process, assessment is the first step. Negative
pressure wound therapy can be painful, especially during dressing changes. The
nurse should assess pain level and premedicate if needed before proceeding with
the procedure .
Q5. A nurse is assessing a client who is gravida 2, para 1. The client is at 41
weeks of gestation and is receiving oxytocin for the augmentation of labor. The
nurse should decrease the infusion rate for which of the following findings?
• A. Contractions are strong to palpation
• B. Cervix is dilating at 1 cm every 4 hr
• C. Consistent contractions last 80 seconds
• D. Contractions occur every 90 seconds
Correct Answer: C. Consistent contractions last 80 seconds
Rationale: Oxytocin should be decreased or discontinued if contractions last
longer than 90 seconds or occur more frequently than every 2 minutes. Contraction
duration of 80 seconds is prolonged and indicates uterine hyperstimulation, which
can lead to fetal distress .
, Q6. A nurse is caring for a client following a suicide attempt. Which of the
following actions should the nurse take first?
• A. Place the client on one-to-one observation
• B. Encourage the client to attend group therapy sessions
• C. Determine if the client has a plan to harm themselves
• D. Ask the client to sign a no-suicide contract
Correct Answer: C. Determine if the client has a plan to harm themselves
Rationale: The nurse must first assess the client's immediate risk for suicide by
asking about suicidal ideation, plan, means, and intent. This assessment guides the
level of observation and interventions needed. One-to-one observation is
implemented based on this assessment .
Q7. Which of the following statements should the nurse make when
responding to a client who is refusing a prescribed medication?
• A. "You can't refuse the medication because your provider has prescribed it
for you."
• B. "I will call your provider to discuss your refusal."
• C. "Why don't you want to take this medication?"
• D. "I'll document that you are refusing to take your medication."
Correct Answer: B. "I will call your provider to discuss your refusal."
Rationale: Clients have the right to refuse treatment. The nurse should respect the
client's decision, notify the provider of the refusal, document the refusal, and
explore the reason for refusal without being confrontational .