Exam 1: Adult

Which of the following clinical manifestations are the most likely indicators of perforation of the gastrointestinal tract?

As a nurse, you must be aware of the visiting policy of the health care center. What would you do if the family of a critically ill patient wishes to spend the night, which is contrary to visiting policy?

A nurse is giving instructions to a patient with an iron deficiency anemia. Which meal plan would reflect the patient's understanding of an appropriate diet?

The nurse is assessing her patient for pressure ulcers. On the patient's right heel, she notices one inch by ½ inch red shallow crater with a small amount of white drainage, surrounded by bright pink skin. She documents this finding as a:

Which type of mechanical ventilation delivers a preset tidal volume each time the ventilator breathes or the patient takes a spontaneous breath?

A patient who had a massive stroke and end stage cancer has been transferred to the floor with comfort care orders. Which pain medication would the nurse expect the doctor to order?

A 67 year old lady is diagnosed of Alzheimer's disease. All of the following medications have been used in the treatment of this disease, except

A patient receiving continuous intravenous heparin for bilateral deep vein thrombosis has an Activated Partial Thromboplastin Time (APTT) 1.4 times the normal value. What would be the next nursing intervention?

For a patient with a massive stroke, when is the best time to begin exercises and physical therapy?

An experienced Intensive Care Unit nurse is precepting a new nurse to the intensive care unit. What would she explain is the most sensitive indicator of neurological change?

A 77 year old male patient is admitted with confusion, a blood glucose level of 1150 mg/dL, confusion, blood pressure of 88/45, heart rate of 120 and serum sodium of 148 and no urine output for the last 12 hours. What order would the nurse anticipate?

A patient taking Dilantin (phenytoin) for a seizure disorder is experiencing breakthrough seizures. A blood sample is taken to determine the serum drug level. Which of the following would indicate a sub-therapeutic level?

What is the most significant complication of intermittent Hemodialysis that the nurse needs to asses for?

The intensive care nurse is taking care of a confused patient who impulsively pulls out his chest tube. What is the first action the nurse should do to protect the chest tube site?

A 54 year old woman has been admitted with a diagnosis of sepsis. What would be the first signs and symptoms that the patient may have a gastrointestinal bleed?

The nurse has finished teaching the patient regarding managing their diabetes at home. Documentation that would protect the nurse against liability would include all of the following except:

What is a major side effect of beta blockers that should be included in patient education?

A patient admitted with acute asthma exacerbation is preparing to be discharged. The nurse is teaching the patient about a peak flow meter. What is the best way to explain what it does?

The importance of evidenced based care is gaining credibility and acknowledgement. Nurses in the critical care setting are often learning new techniques and adapting their care to reflect evidenced based outcomes. Evidence based care would be based on all the following sources except:

A 73 year old woman is brought by her husband of 45 years to you. He is quite concerned because her memory is getting worse with each passing month. She often gets lost of her way to and back from the neighborhood corner store. They have lived in the same house for decades. Recently she has become more anxious and agitated. She has a family history of these symptoms in her older sister who is now 80. What is the most likely disease she has developed?