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SPRING 2024 COMPREHENSIVE EXAM #2
SPRING 2024 COMPREHENSIVE EXAM #2
Total Questions : 32
Showing 10 questions Sign up for moreA nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make?
Explanation
A. This response dismisses the client's concerns and does not address the underlying issue.
B. This response is appropriate, but it does not address the underlying issue of altered taste perception.
C. This response suggests a solution but does not address the underlying issue of altered taste perception.
D. This response acknowledges the client's concerns and provides an explanation for the altered taste perception, which can be reassuring and informative.
A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?
Explanation
A. Reinforce the importance of daily weights. While reinforcing the importance of daily weights is crucial for managing heart failure, it does not address the immediate concern of the patient's weight gain and edema. The nurse needs to take a more direct action to manage the patient's current condition.
B. Call the health care provider for further instructions. Calling the health care provider is a reasonable step, but it may delay immediate intervention that the nurse can perform. Ensuring the patient is taking their prescribed diuretic can provide more immediate relief from fluid retention.
C. Document the findings and continue with the visit. Documenting the findings is necessary for accurate medical records, but it does not address the urgent need to manage the patient's symptoms. Immediate action is required to prevent further complications.
D. Ensure the client has been taking their prescribed diuretic. Ensuring the patient has been taking their prescribed diuretic is the most appropriate immediate action. Diuretics help reduce fluid buildup, which can alleviate the weight gain and edema, providing quick relief and preventing further complications.
A nurse is admitting a client who has anorexia nervosa. Which of the following statements should the nurse expect from this client?
Explanation
A. This statement does not align with the typical behavior of a person with anorexia nervosa. People with anorexia nervosa often have a distorted body image and may fear gaining weight, but they do not typically avoid eating because they do not like the taste of food.
B. This statement is consistent with the behavior of a person with anorexia nervosa. People with this disorder often have specific foods that they fear or avoid because they associate them with gaining weight or losing control over their eating.
C. This statement may be true for some people with anorexia nervosa, but it is not a defining characteristic of the disorder. People with anorexia nervosa often restrict their food intake to a much lower level than 2,000 calories per day.
D. This statement does not align with the typical behavior of a person with anorexia nervosa. People with anorexia nervosa often obsessively track their calorie intake and may keep meticulous records of what they eat.
A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the following lab values indicates the treatment is effective?
Explanation
A. Albumin is a protein that is produced by the liver and is a good indicator of nutritional status. TPN is intended to provide adequate nutrition to the patient, so an increase in albumin levels would indicate that the treatment is effective.
B. Calcium levels are not directly related to the effectiveness of TPN. Calcium levels can be affected by a variety of factors and are not a specific marker for the effectiveness of TPN.
C. Hematocrit (Hct) measures the percentage of red blood cells in the blood. It is not directly related to the effectiveness of TPN.
D. White blood cell count (WBC) is a marker of immune function and is not directly related to the effectiveness of TPN.
A nurse is among the first responders to a mass-casualty incident and does not know what type of personal protective equipment (PPE) is needed. Which of the following actions should the nurse take?
Explanation
A. Using a dosimeter to measure radiation levels may be necessary in certain situations, but it is not the first step in determining what type of PPE to use.
B. Choosing the highest level of protection equipment available is important in minimizing the chances of the provider contacting the disease.
C. Waiting before delivering care might lead to loss of valuable time.
D. Decontaminating victims before intervening is not the nurse's responsibility. The focus should be on protecting oneself and providing care to those who need it.
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)
Explanation
A. A weakened gag reflex is a common complication of cervical spinal cord injuries and can lead to difficulty swallowing and increased risk of aspiration.
B. Hyperthermia can occur due to autonomic dysreflexia, a common complication of cervical spinal cord injuries.
C. Absence of bowel sounds can indicate a paralytic ileus, a common complication of cervical spinal cord injuries.
D. Polyuria is not a common complication of cervical spinal cord injuries. It may occur due to other factors, such as diabetes insipidus, but it is not directly related to the injury itself.
E. Hypotension can occur due to autonomic dysreflexia, a common complication of cervical spinal cord injuries.
A home health nurse is working with assistive personnel (AP) to care for a client in their home. Which of the following tasks can the nurse assign to the AP?
Explanation
A. Reviewing the client's medications requires a higher level of education and training than most assistive personnel have.
B. Notifying the case manager of the client's wishes for community resources requires a higher level of education and training than most assistive personnel have.
C. Assisting the client with bathing and oral care is within the scope of practice for most assistive personnel.
D. Assessing the client's wound requires a higher level of education and training than most assistive personnel have.
A client in the hospital is prescribed digoxin (Lanoxin) 125 mcg. The computerized medication delivery system on the unit dispenses tablets labeled digoxin 0.25 mg. How many tablets should the nurse dispense to the client?
Explanation
To calculate the number of tablets the nurse should dispense to the client, we need to convert the prescribed dose of digoxin from milligrams (mg) to micrograms (mcg), as the tablets are labeled in milligrams.
1 mg = 1000 mcg
125 mcg = (125 mcg) / (1000 mcg/mg) = 0.125 mg
Now, we can determine the number of tablets needed to achieve this dose:
0.125 mg ÷ 0.25 mg/tablet = 0.5 tablets
A nurse is preparing to obtain a blood specimen from a client by venipuncture. The client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. Which of the following sites should the nurse plan to use to obtain the blood specimen?
Explanation
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- The foot is not a typical site for obtaining a blood specimen by venipuncture.
- This arm is not ideal for venipuncture because the client is receiving IV fluids through an IV catheter in the basilic vein of the right forearm.
- The left forearm is a suitable site for venipuncture because the client is receiving IV fluids through an IV catheter in the basilic vein of the right forearm.
- The right forearm is not ideal for venipuncture because the client is receiving IV fluids through an IV catheter in the basilic vein of the right forearm.
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A nurse is caring for a client who was recently diagnosed with an opioid use disorder. They were a student in a local community college but were recently dismissed for failing their classes. Their previous diagnoses include anxiety, Crohn's disease, and chronic back pain due to a gymnastics injury in high school. Which of the following should the nurse identify as potential underlying reasons why the client might have started using opioids?
Explanation
A. While parental influence can play a role in substance use disorders, there is no information in the scenario to support this as a potential underlying reason for the client's opioid use.
B. Chronic pain, such as that caused by Crohn's disease and a gymnastics injury, can lead individuals to seek relief through opioid use. Additionally, opioids may be used to selfmedicate underlying anxiety.
C. There is no mention of hallucinations in the client's history, and using opioids to perform better at work is not a typical reason for opioid use disorder.
D. While opioids can induce drowsiness and promote sleep, this is not typically a primary reason for developing an opioid use disorder in individuals with chronic pain conditions.
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