NUR283 Comp Exam 1 With 100% correct answers 2025-2026 already graded A+

Medications should be given through what?

Central line

The nurse working on a medical surgical unit is delegating tasks to unlicensed personnel. Which of the following delegated task would REQUIRE FOLLOW UP by the charge nurse?

A. Assisting a client who had a paracentesis 2 hours ago to get out of bed for the first time.

Rationale – anytime a client is doing something for the first time the RN needs to do it

The nurse is prioritizing patient care after a change of shift report. The nurse should first plan to see the patient who:

B. Had an endoscopic retrograde cholangiopancreatography 30 minutes ago and is reporting difficulty swallowing Rationale – Difficulty swallowing – ABC’s!

The nurse working on the mom/baby unit has become aware of the following client situations. Which of the following clients should the nurse INITIALLY assess?

C. a neonate who is 4 hours old, whose resting HR is 95 BPM.

Rationale – Normal HR for a newborn is 120-140 BPM – 95 is a LOW BPM

A nurse working on a medical surgical unit has just received a handoff report on the following clients. The nurse should FIRST plan to assess the client who has:

D. Acute pancreatitis and is reporting the development of pain on deep inspiration

Rationale – “acute” if not caught early, will possible burst and patient will become septic

The nurse working on a pediatric unit is caring for the following children who have been admitted in the past 12 hours. It would be a priority goal for the nurse to initiate an interdisciplinary conference for the child who:

A. 5 yr old with diagnosed cystic fibrosis at birth and has been hospitalized 4 times in the past 2 months

Rationale – This is conferencing everyone!!! PT, dietary, spiritual guidance, everyone should be conferenced for this patient. This question is asking – WHO / WHICH child is requiring the MOST help and resources???

The nurse working in the ED has received the following prescriptions for a newly admitted client. Which prescriptions should the nurse implement FIRST?

D. Initiate IV sodium and potassium for a client admitted with diarrhea and dehydration who has a serum potassium level of 2.9.

Rationale – serum potassium of 2.9 is CRITICAL -this is a critical lab value and should be addressed first!

A nurse is working in a community health clinic is assessing clients who are waiting to be seen. Which client should the nurse have the primary health care provider see FIRST?

A. a 57 year old with graves disease with a temperature of 100.5

Rationale – Thyroid issue

A nurse is working on a pediatric cardiac unit is reviewing the telemetry monitors for assigned clients. Which client should the nurse INITIALLY plan to assess?

A. 2 year old toddler who is walking in the hallway and has a HR of 160 BPM

Rationale – Abnormal HR – all the other choices were normal for the child

A nurse is caring for a male client who has a deep partial thickness and a full thickness burn to 45 % of the lower body. It would be a PRIORITY for the nurse to notify the primary health care physician if the client has:

D. A urinary output of 45 ml over the past two hours

Rationale – Normal urinary output per hour is 30 ml.hr. This question really has nothing to do with “burn” and more know your normal values.

The nurse is assessing clients at the scene of a mass casualty disaster and is prioritizing care based on the disaster triage tag system. Which of the following clients should be transported to the health care facility FIRST?

C. the client who has multiple compound fractures and is reporting chest pain Rationale – patient is reporting chest pain

The charge nurse in the ED is reviewing the care provided for recently admitted clients. which of the following reflects implementation of an accepted standard of care?

B. placing the client who has suspected Hemophilus influenza on droplet precautions

Rationale – influenza = droplet

A charge nurse is planning to admit several clients in the medical unit. It would be necessary for the nurse to admit which client to a PRIVATE room?

B. Has a fever of unknown origin

3 multiple choice options

Sequence for “doffing” (removing) personal protective equipment

(PPE)

Gloves

Goggles

Gown

Mask

A nurse is caring for a client who has a sealed radiation implant. Which of the following precautions should the nurse implement

D. Wear the lead shield while providing client care

3 multiple choice options

A preceptor is working with a newly hired nurse who is preparing to perform a sterile dressing change. Which of the following actions by the newly hired nurse would require INTERVENTION by the preceptor?

A. Putting on sterile gloves prior to opening the outer packaging

The nurse is teaching a class on health promotion and illness prevention. Which of the following actions by the nurse is an example of secondary prevention?

B. Performing monthly self-breast examinations

3 multiple choice options

The nurse has instructed a client who regularly menstruates about performing self-breast examinations at home. Which of the following client statements indicates correct understanding of the teaching?

A - I will perform my self breast examination 7 days after my period ends - you do it 7 days post as the hormones have decreased and any natural lumps will disappear, and breasts will not be as tender and sore

A nurse is teaching a female client about positive signs of pregnancy. Which of the following client statements would indicate a correct understanding of the teaching?

A – Heartbeat

Rationale – the only positive signs of pregnancy is heartbeat and lung sounds. Remember there are positive signs of pregnancy and presumptive signs of pregnancy.

A nurse is teaching a mother of a five-year-old child about age appropriate toys. Which of the following toys would be appropriate for the nurse to recommend?

A – doll and coloring book

Rationale – Do not pick the 100 piece puzzle

The nurse is caring for a pregnant client whose last menstrual period began on October 21st. Using Naegele’s rule, which of the following dates would be the due date?

A – July 28th

Rationale – add 7 days – then subtract 3 months

The nurse is planning care for a newly admitted client who has major depressive disorder following the death of her newborn 2 weeks ago. Which of the following goals should the nurse identify as the priority?

A. signing a no-harm contract

Rationale – This question is a safety question!! If the nurse could go in and do 1 thing, what would it be – it would be safety for the client!

3 multiple choice options

The nurse is caring for a patient who has paranoid schizophrenia and a history of auditory hallucinations. The client is yelling and pacing in the dayroom “I will do it”. What of the following actions will the nurse take?

A. obtaining increased supervision for the client

Rationale – you cannot divert someone who has auditory hallucinations

2 multiple choice options

The nurse working in the psychiatric inpatient unit is caring for a client who has bi-polar disorder and is in the manic phase. The client states to the nurse, “I am bored.” Which of the following activities is appropriate for the nurse to suggest to the client?

A. walking with the nurse in the courtyard

Rationale – Don’t do anything with the client that is competitive or controversial topics

2 multiple choice options

The nurse is working on a crisis hotline, speaking with a client who states, “I just took an entire bottle of amitriptyline.” Which of the following responses should the nurse INITIALLY make to the client?

A – I’m glad you called and I want to send an ambulance to help you

The nurse is caring for a client who is currently prescribed bed rest. Which of the following actions should the nurse take to help prevent the development of pulmonary embolism?

C. instruct the client to perform leg exercises

Rationale – ROM will help to prevent a DVT, which if formed could break off and travel to the lungs resulting in a pulmonary embolism. Incentive spirometer are to prevent pneumonia and atelectasis.

2 multiple choice options

The nurse has instructed a client who must ambulate with a cane. Which of the following client statements indicates a correct understanding of the teaching?

A – I will place the cane on the side of the unaffected limb and walk with the weaker leg first.

Rationale – the cane goes on the side where the leg is strongest.

The nurse has provided dietary teaching to a client who recently had a surgical colostomy placed. Which of the following statement made by the client indicates a correct understanding of the instructions?

A. Eating yogurt can help decrease the amount of gas that I have

Rationale – none of the other answers make sense. Largest meal should not be in the evening, the bag will be filled up by the morning.

3 multiple choice options

The nurse has instructed a female client who recently received hearing aids. Which of the following client statements indicates the need for ADDITIONAL teaching?

A. I will clean the hearing aids with alcohol wipes - This is a false statement!!

Rationale – you are looking for the incorrect statement in the answer – you clean your hearing aids with plain soap and water – NOT alcohol wipes

3 multiple choice options

The nurse has instructed the client who has a UTI about prescribed drug – ciprofloxacin. Which of the following instructions should the nurse give the client?

A – You should report the development of tendon pain while taking this medication, since tendon rupture is a potential complication

Rationale – Know u DRUGS!

A nurse is teaching a client who had a spontaneous abortion about the need to receive a RhoGam shot. Which of the following client statements indicates a need for further teaching?

C. This medication will allow my body to fully remove the placenta lining – This is a FALSE statement!!

Rationale – RhoGam is given for the mom so that she does not develop antibodies toward an A+ baby. RhoGam is given once per pregnancy.

3 multiple choice options

The nurse is teaching a group of clients about insulin administration. Which of the following information should the nurse include?

A - Insulin absorption is fastest when injected into the abdomen

The nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 out of 10. The nurse administers 1 sublingual nitroglycerin tablet. After 5 minutes, the client states the pain is a severity level of 3. Which of the following actions should the nurse be prepared to do next?

A – administer another nitro sublingual tablet

Rationale – The focus of this question is about the drug. This is a medication question!

The nurse has provided medication instruction to a patient who has asthma and has been prescribed beclomethasone. Which of the following client statements indicates a correct understanding of this instruction?

A. I should rinse my mouth out after this medication

Rationale – Beclomethasone is a corticosteroid – it is a daily use inhaler to prevent asthma flare ups, it is NOT a rescue inhaler. It can increase the risk of oral thrush, therefore you need to rinse your mouth after each use.

3 multiple choice options

The nurse is caring for a client who is receiving a prescribed magnesium sulfate IV. Which of the following client findings would indicate the client is experiencing a side effect of that medication?

A. A respiratory rate of 10 breaths per minute

3 multiple choice options

The primary health care provider has prescribed ampicillin 150 mg PO 3 times a day to a toddler that weighs 22lbs. The drug available is ampicillin suspension that is 250mg/5ml. Which action should the nurse take?

A – Administer 3ml

Rationale – this is a math question – do the math. You have what you need to figure this out – this is not a matter of clarifying the order, do the math

The nurse is preparing to administer prescribed medication to the following client. It would be essential for the nurse to follow up with the primary health care provider for the client who has?

A. Diabetes mellitus, just had a CT scan with IV contrast and has been prescribed metformin

Rationale – CT contrast – cannot receive Metformin within 48 hours

3 multiple choice options

The nurse has provided discharge teaching to a client who had an open radical prostatectomy and has been discharged home with a urinary catheter. Which of the following statements made by the patient would require FOLLOW UP by the nurse?

A. I will not be able to take a shower for the next 2 weeks

3 multiple choice options

The nurse is monitoring a client following a thoracentesis. It would be a priority for the nurse to notify the primary health care provider if the client develops......

A. a heartrate that has increased from 95 to 110BPM

Rationale – this is a priority question, all other answers are expected findings, the O2 saturation is still within normal limits. This question is really asking about complications following a thoracentesis, technically the HR should not increase as the heart can perform normally as it has the room it needs.

3 multiple choice options

The nurse is caring for a 2-month-old infant that is postoperative following a surgical repair of a left cleft lip and is crying ….

A. Rock the baby

Rationale – this is a “comfort” question

1 multiple choice option

The nurse is caring for a client who has developed hypovolemic shock and has a heartrate of 160BPM and is receiving oxygen @ 2L via nasal cannula. Which of the following actions would be PRIORITY for the nurse to perform?

D – administer the prescribed NS @ 150ml/hr

Rationale – hypovolemic shock is what? Low fluid/volume! Give the prescribed medication which is normal saline. Their HR is tachy, and the keyword is administer the prescribed medication!

3 multiple choice options

The nurse is caring for a client that has acute kidney injury. Which of the following arterial blood gas results would the nurse EXPECT to find?

Metabolic Acidosis

A. PH 7.26 PAO2 90 PACO2 30 HCO3 14 SAO2 95

The nurse is caring for a 3-year-old who has had 160ml of urine output over the past 8-hour period. The child weighs 33 pounds. Which of the following actions should the nurse take?

D- Continue to monitor

Rationale – this is an expected finding -?? (look up in Saunders how to do math for urine output for child)

3 multiple choice options

The nurse is caring for a client who had abdominal surgery and has developed an evisceration. After calling for assistance, which of the following actions would the nurse take next?

B. Use a moist ABD to cover the abdomen

Rationale – Call, cover, splint – Client should be placed in a semi fowlers position, this reduces pressure on the abdominal wall. Moist dressing prevents drying of the organs.

1 multiple choice option

The nurse is caring for a client that develops the following cardiac rhythm –

A - PVC - check potassium

The nurse is working in the PACU is assessing the client who had a below the knee amputation. The nurse should give priority to assess the client for?

A. Hypovolemic shock - possible bleeding

1 multiple choice option

The nurse is assessing the client who has a suspected retinal detachment of the left eye. Which of the following client statements would be consistent with this diagnosis?

A. I see floating dark spots in my left eye

1 multiple choice option

The nurse is assessing a client who has developed Addisonian crisis. Which of the following findings is consistent with this diagnosis?

A - a blood glucose of less than 60

The nurse is caring for a client who had lumbar spinal surgery 8 hours ago. It would be a priority for the nurse to notify the surgeon if

C. Has a moderate amount of clear drainage on the surgical dressing

2 multiple choice options

The nurse is planning care for a client who is on bed rest, the client has end stage cirrhosis of the liver with hepatorenal failure and abdominal ascites which of the following interventions should the nurse be prepared to implement?

A - provide the client with a low sodium diet

1 multiple choice option