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Comprehensive Nursing Exam
Preparation Resources
Therapeutic Play for Preschoolers Undergoing
Surgery
A nurse on the pediatric unit is assisting with the plan of care for a preschooler who will have a surgical procedure in the morning. The nurse should recommend engaging the child in therapeutic play for the care plan because it offers the following benefits:
Allows the child to manipulate toy medical equipment, which can help reduce anxiety and fear about the upcoming procedure.
Celiac Disease in School-Age Children
A nurse is collecting data from a school-age child who has celiac disease. The nurse should expect the following finding:
Steatorrhea, which is the presence of excess fat in the stool, is a common symptom of celiac disease in school-age children.
Insomnia in Hospice Clients
A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. The nurse should identify the following practice as contributing to the client's insomnia:
The client watches television in her bed during the day, which can disrupt the sleep-wake cycle and contribute to insomnia.
Calcium Sources for Lactose-Intolerant
Pregnant Clients
A nurse is caring for a client during her first prenatal visit and notes that she is lactose intolerant. The nurse should include the following food on the list of calcium sources for this client:
Collard greens, which are a good source of calcium for those who are lactose intolerant.
Vaginal Yeast Infections during Pregnancy
A client at a routine prenatal care visit asks the nurse if it is common to develop vaginal yeast infections during pregnancy. The nurse should make the following response:
The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common.
Physiologic Adaptations to Pregnancy
A nurse in a prenatal clinic is collecting data from several clients. The nurse should identify the following client report as an expected physiologic adaptation to pregnancy:
Breast tenderness, which is a common physiologic change during pregnancy.
Epistaxis Management in Children
A nurse is caring for a child who has epistaxis (nosebleed). The nurse should take the following action:
Apply continuous pressure to the lower part of the child's nose to help stop the bleeding.
Prioritizing Laboratory Findings in CKD
A nurse is reviewing the laboratory report for a client who has chronic kidney disease (CKD). The nurse finds the following laboratory test results: potassium 6.8, calcium 7.4, hemoglobin 10.2, and phosphate 4.8. The nurse's priority finding to report to the provider is:
Hyperkalemia, as an elevated potassium level is a critical finding that requires immediate attention.
Diaphragm Use Recommendations
A nurse at a family planning clinic is preparing to give a presentation to clients about to use a diaphragm. The nurse should plan to include the following information:
Use spermicidal jelly whenever you use your diaphragm, as this helps to enhance the effectiveness of the diaphragm.
Colorectal Cancer Prevention Education
A nurse is assisting to plan teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. The nurse should recommend including the following topic:
The importance of colonoscopy screening starting at age 50 years old, as this is a key recommendation for colorectal cancer prevention.
Reinforcing Suicide Precautions with Newly
Licensed Nurses
A nurse delegates a newly licensed nurse to provide one-on-one observation for a client who requires suicide precautions. The following action by the newly licensed nurse indicates the need for further reinforcement of teaching:
Ambulates the client's roommate while the client sleeps, as this would not provide the required continuous observation for a client on suicide precautions.
MRSA Infection Precautions for Dietary
Assistants
A nurse is caring for a client who has a MRSA infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. The nurse should give the dietary assistant the following instructions:
Don gloves when entering the room and use hand sanitizer when exiting, to prevent the spread of the MRSA infection.
Care Plan for Clients in Balanced Skeletal
Traction
A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize her femur fracture. The nurse should recommend the following action for the client's plan of care:
Offer the client a diet high in fluid and fiber, as this can help prevent constipation, which is a common issue for clients in traction.
Adverse Effects of Ethambutol in Tuberculosis
Treatment
A nurse is collecting data from a client who has tuberculosis and a prescription for ethambutol. The nurse should inform the client that they are
likely to develop the following alteration as an adverse effect of this medication:
Loss of red/green color discrimination, which is a common adverse effect of ethambutol.
Priority Data Collection in the Fourth Stage of
Labor
A nurse is assisting with the care of a client who had a precipitous delivery. The nurse should identify the collection of the following data as a priority during the fourth stage of labor:
Palpating the client's uterine fundus to assess for proper involution and detect any bleeding.
Prioritizing High-Risk Newborn Visits
A community health nurse is contributing to the plan of care for high-risk newborns who were discharged yesterday. The nurse should recommend caring for the following newborn first:
A four-day-old newborn who has an elevated bilirubin level and requires phototherapy, as this is a critical condition that requires prompt intervention.
Addressing Concerns about Prolonged
Hospitalization
A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. The nurse should make the following statement:
"Tell me what concerns you most about being hospitalized," as this allows the nurse to address the client's specific concerns.
Differentiating Angina Pectoris and
Myocardial Infarction
A nurse is reinforcing teaching for a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction. The nurse should identify the following manifestations as indications of a myocardial infarction:
Diaphoresis, dizziness, anxiety, impending doom, nausea, and vomiting, which are more severe and indicate a myocardial infarction rather than angina pectoris.
Identifying Impending Airway Obstruction in
Laryngotracheobronchitis
A nurse in an urgent care center is collecting data from an infant who has laryngotracheobronchitis. The nurse should report the following finding to the provider as an indication of impending airway obstruction:
Nasal flaring, which can be a sign of increased respiratory effort and impending airway compromise.
Medication Administration Verification
Procedures
A nurse is preparing to administer medications to a client who is unconscious. The nurse should perform the following verification procedure:
Compare the medical record number and name on the medication administration record with the client's identification band to ensure the correct client is receiving the medications.
Improving Orientation in Clients with
Dementia
A nurse at a long-term care facility notes that a client who has dementia is having problems with orientation. The nurse should take the following action to improve the client's level of orientation:
Post a large calendar on the bulletin board, as this can help provide visual cues and orientation for clients with dementia.
Medication Management for Chronic Phantom
Limb Pain
A nurse is caring for a client who has chronic phantom limb pain following an above-the-knee amputation. The nurse should verify the following medication prescription with the provider:
Meperidine, as this opioid medication may be prescribed to manage the client's chronic phantom limb pain.
Laboratory Findings in Dehydration
A nurse is caring for a client who has dehydration. The nurse should expect the following laboratory value for this client:
Hematocrit 55%, as dehydration can lead to hemoconcentration and an elevated hematocrit.
LASIK Surgery Discharge Teaching
A nurse is reinforcing teaching with a client who is scheduled for LASIK surgery. The nurse should include the following information:
"Your procedure will only take 10 to 15 minutes per eye," as this can help set appropriate expectations for the client.
Addressing Dietary Restrictions Based on
Religious Beliefs
A provider tells a client who reports practicing Hinduism that at 12 weeks gestation, she needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. The nurse should make the following response:
"Let's discuss other foods that are also high in protein that you could substitute for meat," as this allows the nurse to address the client's concerns while providing alternative protein sources that align with her religious beliefs.
Managing Aggressive Behavior in Clients with
Antisocial Personality Disorder
A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. The nurse should use the following approach to manage the client's behavior:
Speak to the client with clear, calm, caring statements, as this can help de-escalate the situation and maintain a therapeutic environment.
Responding to Grief and Loss in Adolescent
Clients
A nurse is caring for an adolescent client who gave birth to a stillborn preterm fetus. The client is crying and says to the nurse, "Why did this happen to me?" The nurse should make the following response:
"This must be so difficult for you," as this empathetic statement acknowledges the client's grief and provides emotional support.
When reinforcing discharge teaching for a client who has had a TIA, the nurse should include instructions to reduce dietary sodium. Limiting sodium intake can help manage hypertension, a major risk factor for TIA.
Client Positioning and Mobility
When caring for a client receiving mechanical ventilation, the nurse should recommend maintaining the head of the bed at 30 degrees. This position helps to prevent aspiration and improve ventilation. When reinforcing body mechanics with assistive personnel, the nurse should include instructions to sit with a supported back, keep knees at hip level, and use an ergonomically designed computer keyboard. Proper body mechanics can prevent musculoskeletal injuries.
Recreational Activities
For a young adult client with an acute exacerbation of schizophrenia, the nurse should recommend walking with a staff member as a recreational activity. This provides physical activity and social interaction, which can be beneficial for clients with schizophrenia. When selecting toys for a toddler during hospitalization, the nurse should choose a 10-piece wooden puzzle. This type of toy is appropriate for the toddler's developmental stage and can promote cognitive and fine motor skills.
Infection Control
When assisting with the admission of a client who has manifestations suggestive of tuberculosis, the nurse's priority action is to initiate airborne precautions. This helps to prevent the transmission of the disease to other clients and healthcare workers.
Transfusion Reactions
If the nurse suspects a transfusion reaction in a client receiving a blood product, the nurse's first action should be to stop the infusion. This helps to prevent further complications and allows for appropriate interventions.
Abuse and Neglect
If a nurse in an urgent care center suspects child abuse based on the client's bruises, the nurse should report the suspected abuse to local authorities. This is a mandatory reporting requirement to protect the child's safety.
Hydration Assessment
When caring for an infant experiencing dehydration, the nurse's priority data to collect is the client's daily weight. Monitoring weight changes is the most reliable indicator of hydration status in infants.
Schizophrenia and Voting
When a client with schizophrenia asks about voting in an upcoming election, the nurse should respond by saying, "We can work together to find out how you can get a mail-in ballot." This approach helps the client participate in the electoral process while considering their mental health needs.
Osteoporosis Risk Factors
When educating a group of clients at a senior center about the risk factors for osteoporosis, the nurse should include the statement "Extended periods of immobility increase your risk for osteoporosis." This is an important risk factor that the clients should be aware of.
Abdominal Aortic Aneurysm (AAA) Expansion
When collecting data from a client with an abdominal aortic aneurysm (AAA), the nurse should recognize that a report of sudden severe back pain may indicate that the AAA is expanding. This is a critical finding that requires immediate medical attention.
Dietary Restrictions with Phenelzine
When reinforcing dietary instructions for a client taking phenelzine to treat depression, the nurse should recognize that the selection of chicken salad for the client's lunch indicates an understanding of the dietary restrictions. Clients on phenelzine must avoid foods high in tyramine to prevent a hypertensive crisis.
HIV Exposure in Infants
When assisting with planning care for an 18-month-old infant who has tested positive for HIV, the nurse should consider that the infant's mother is likely also HIV-positive. This is an important factor in the infant's care and treatment plan.
Developmental Milestones
When discussing growth and development with the parent of a 4- month-old infant, the statement "My baby loves to play with pillows in her crib" indicates that the parent needs further instruction. Infants of this age should not have loose bedding or objects in their crib due to the risk of suffocation.
Medication Therapy for Systemic Lupus Erythematosus
(SLE)
When caring for a client with a new diagnosis of acute systemic lupus erythematosus (SLE), the nurse should expect to administer corticosteroids as part of the medication therapy. Corticosteroids are a common treatment for managing the inflammatory and autoimmune aspects of SLE.
Confidentiality in Client Care Discussions
During a client care staff meeting, the charge nurse should identify the unit medication room as an acceptable area for discussing confidential client information. This environment is private and limits the potential for overheard conversations that could breach client confidentiality.
Autism Spectrum Disorder and Routines
When reinforcing teaching with the family of a child with autism spectrum disorder, the statement "It will help our child if we structure our daily routine" indicates that the family understands the importance of maintaining a consistent routine for children with this disorder.
Alcohol Intoxication and Injury
In an urgent care center, the nurse should report the client who is difficult to arouse and unable to respond to questions first to the charge nurse. This client's level of consciousness and responsiveness suggest a more severe condition that requires immediate attention.
Zidovudine and Decreased Hemoglobin
When collecting data from a client with AIDS who is taking zidovudine, the nurse should prioritize reporting a decreased hemoglobin to the provider. Zidovudine can cause bone marrow suppression, leading to anemia, which is a significant adverse effect that requires medical intervention.
Mandatory Education and Compliance
As a charge nurse in a long-term care facility, the nurse should plan to send an email to each nonadherent employee that includes a link to upcoming educational sessions on extremity restraint safety. This approach ensures that all staff members receive the required training and promotes compliance with mandatory educational requirements.
Hyperthyroidism Management
When reinforcing teaching with a client who has hyperthyroidism, the nurse should recommend increasing the client's caloric intake with
meals. Hyperthyroidism can increase the body's metabolic rate, leading to weight loss, and increased caloric intake can help manage this symptom.
Lamotrigine and Rash
When reinforcing teaching with the parent of a child with a new prescription for lamotrigine to treat a seizure disorder, the nurse should instruct the parents that the priority adverse effect to report to the provider is the development of a rash. Lamotrigine can cause a potentially life-threatening rash, and prompt medical attention is crucial.
Seizure Management
When responding to a call from an assistive personnel about a client who has had a seizure and is unconscious, the nurse's first action should be to check the client's airway patency. Maintaining a patent airway is the priority in managing a client who has experienced a seizure.
Oxygen Delivery Methods for COPD Clients
Nasal Cannula
In the client's medical record, the nurse notes a history of COPD (Chronic Obstructive Pulmonary Disease). For this client, the nurse should recommend the use of a nasal cannula as the appropriate oxygen delivery method.
Fostering Rapport and Engaging a School-Age
Child
Discussing Favorite Videogames
When caring for a school-age child on a pediatric mental health unit, the nurse should make the following statement to foster rapport and engage the child in conversation: "Tell me about your favorite videogame."
Assisting an Older Adult Client with Dementia
Inappropriate Assistance
In a long-term care facility, the nurse hears an AP (Assistive Personnel) talking with an older adult client who has dementia with periods of confusion. The following statement by the AP indicates that they require further instructions: "Let me do your hair for you and brush your teeth."
"It is likely that ginkgo biloba will interfere with the effectiveness of his other medications."
Preventing Recurrent Urinary Tract Infections
Hygiene Recommendations
When a female client who has recurrent cystitis asks the nurse about preventing future episodes, the nurse should provide the following reinforcement of teaching: "Avoid tub baths and prefer showering instead."
Postoperative Complications
Pulse Oximetry Findings
When caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson Pratt drain in place, a pulse oximetry reading of 85% should indicate to the nurse that the client is developing a postoperative complication.
Clostridium Difficile Infection Management
Hand Hygiene Prioritization
When caring for a client who has pseudomembranous colitis due to Clostridium difficile infection (CDI), the nurse's priority intervention is performing hand hygiene before and after contact with the client.
Albuterol MDI Technique
Proper Inhalation Steps
When reinforcing teaching with a client about how to use an albuterol metered-dose inhaler (MDI), the nurse should instruct the client to perform the following steps in order: "Hold the mouthpiece 1 to 2 inches in front of your mouth, tilt your head back slightly and open your mouth wide, depress the canister while taking a slow deep breath, and hold your breath for 10 seconds."
Preschooler Sleep Routine
Establishing a Consistent Bedtime Routine
When talking with a parent of a preschooler who reports that her child grows upset at night and does not go to bed at a consistent time, the nurse should give the following instruction: "Use a stable relaxing routine such as a bath and bedtime story before bed."
Identifying Potential Malignant Melanoma
Irregular Skin Lesion Characteristics
When caring for a client who has regular occupational exposure to sunlight and comes to the clinic for evaluation of several skin lesions, the nurse should be alerted to the possibility of malignant melanoma by the finding of an irregularly shaped brown lesion with light blue areas on the neck.
Implementing a New Charting System
Collecting Staff Input
Before the implementation date of a new computerized charting system, the charge nurse should first take the action of collecting staff input about planning and implementing the change.
Managing Type 1 Diabetes During Illness
Recognizing Appropriate Illness Management
When reinforcing teaching with the parent of a child who has type 1 diabetes on how to manage the child's disorder during illness, such as a cold, the following statement by the parent indicates an understanding of the teaching: "I'll check his blood glucose more often."
Contraindications for Sildenafil Citrate
Nitrate Use for Heart Failure
When reviewing the medical record of a client who has requested a prescription for sildenafil citrate, the nurse should identify the client's current use of nitrates to treat heart failure as a contraindication for the use of this medication.
Cast Care Instructions
Elevation Recommendation
When reinforcing teaching with a school-age child who has just had a fiberglass cast application following a lower extremity fracture, the nurse should reinforce the following instruction with the child and their parents about care during the first 48 hours: "Keep the cast above the level of your heart."
Diabetes Management and Dietary
Adjustments
Modifying Pasta Intake
When reinforcing teaching with a client who has type 2 diabetes and states, "I eat pasta every day," the nurse should respond: "You don't have to give up pasta; just adjust the amount you eat."
Tuberculosis Exposure Evaluation
Interpreting Mantoux Test Results
When evaluating the injection site for a client who had a Mantoux skin test 48 hours ago and finds 10 mm of induration with slight redness, the nurse should conclude that "The client has had an exposure to tuberculosis."
Cochlear Implant Function
Direct Nerve Stimulation
When reinforcing teaching with a client about treatment options for profound sensorineural hearing loss, the nurse should include the following information about the function of cochlear implants: "Transmits impulses directly to the auditory nerve endings."
Addisonian Crisis Prevention
Hydrocortisone Prescription
When assisting with the care of a client who has Addison's disease and presents to the emergency department reporting nausea, vomiting, diarrhea, and abdominal pain, the nurse should expect that the provider will prescribe hydrocortisone to prevent an Addisonian crisis.
Preparing for an EEG
Hair and Styling Product Recommendations
When reinforcing teaching with a client who is going to have an EEG (Electroencephalogram) in the morning, the nurse should provide the following information: "Shampoo your hair before the procedure, and don't put any styling products on it afterward."
Family-Centered Care Approach
Discussing Home Care Options
When a client with a terminal illness has a family who wants to care for the client at home, the following statement by the nurse indicates an understanding of family-centered care: "Let's set up a meeting with the doctor to discuss your options for home care."
Metoprolol Discharge Instructions
Medication Management Recommendations
When reinforcing discharge teaching with a client who has a new prescription for metoprolol, the nurse should include the following instructions: "Do not stop taking his medication abruptly, count your radial pulse daily, change positions slowly."
Hearing Aid Troubleshooting
Identifying Excessive Earwax
When caring for an older adult client who has an in-the-canal hearing aid and states that the hearing aid is making a whistling sound, the nurse should identify excessive wax in the ear canal as a source for this sound.
Delegating Postoperative Care
Monitoring Urinary Output
When planning to delegate the postoperative care of a client following an appendectomy, the nurse should assign the following action to assistive personnel: "Record urinary output after emptying the indwelling urinary catheter."
Identifying Coping Mechanisms in Substance
Use Disorder
Intellectualization
When interacting with a client in a substance use disorder program, the following statement indicates that the client is using intellectualization as a way of coping with the anxiety of admission: "I have read that problems with substance can have a variety of predisposing factors."
