Question 1

The nurse receives hand-off report on assigned clients.  Which client should the nurse assess first?

Accepted Answer

A) Client 1 day post femoral-popliteal bypass surgery who now has a nonpalpable pedal pulse present only with Doppler 
B) Client with chronic venous insufficiency who has edema and brown discoloration of the lower extremities 
C) Client with peripheral arterial disease and gangrene of the foot who has a cool-to-the-touch, hairless extremity 
D) Client with peripheral arterial disease who reports severe cramping pain in the calf with activity such as walking

Question 2

The nurse assesses a client with a history of cystic fibrosis who is being admitted due to a pulmonary exacerbation.  Which assessment finding requires immediate action by the nurse?

Accepted Answer

A) Decrease in SpO2 from baseline 92% to 88% on room air 
B) Expectorating blood-tinged sputum 
C) Loss of appetite and recent 5 lb (2.3 kg) weight loss 
D) No bowel movement for 2 days and right lower quadrant discomfort

Question 3

The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites, and esophageal varices.  Which statement by the client indicates that the teaching was effective?

Accepted Answer

A) "I may have one alcoholic drink a day, but no more." 
B) "I may take aspirin instead of acetaminophen for fever or pain." 
C) "I should avoid straining while having a bowel movement." 
D) "I should eat a protein- and sodium-restricted diet."

Question 4

The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer.  The client is concerned because the health care provider said there was damage to the ninth cranial nerve.  Which statement made by the nurse is most appropriate?

Accepted Answer

A) "I will ask the health care provider to explain the consequences of your procedure." 
B) "This is a common complication that will require you to have a hearing test every year." 
C) "This is a common complication; your health care provider will order a consult for the speech pathologist." 
D) "This is the reason you are using a special swallowing technique when you eat and drink."

Question 5

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg.  The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg.  Which action by the nurse is most appropriate?

Accepted Answer

A) Give the antihypertensive medication 
B) Monitor the blood pressure 
C) Notify the health care provider 
D) Question the prescription

Question 6

A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort.  The nurse assesses the client's abdomen by pressing one hand firmly into the abdominal wall.  The client experiences pain when the nurse quickly withdraws the hand.  The client's most recent blood glucose level is 210 mg/dL (11.65 mmol/L).  What is the priority action by the nurse?

Accepted Answer

A) Collect peritoneal fluid for culture and sensitivity 
B) Heat the remaining dialysate fluid and increase the dwell time 
C) Place the client in high Fowler's position 
D) Prepare to administer regular insulin intravenously

Question 7

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused.  The client is scheduled for discharge later today.  Which interventions are appropriate for the nurse to implement?  Select all that apply.

Accepted Answer

A) Assess the client's hand movements with the arms extended 
B) Compare current mental status findings with those from previous shifts 
C) Contact the health care provider to request a blood draw for ammonia level 
D) Encourage the client to ambulate in the hallway 
E) Hold the client's morning dose of lactulose

Question 8

The emergency department nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury.  Which assessment finding is consistent with injury to the occipital lobe?

Accepted Answer

A) Decreased rate and depth of respirations 
B) Deficits in visual perception 
C) Expressive aphasia 
D) Inability to recognize touch

Question 9

A nurse is caring for a client 1 day after a left-sided mastectomy with lymph node dissection.  Which nursing intervention is the priority in caring for this client?

Accepted Answer

A) Apply an ice pack to the left shoulder 
B) Elevate the affected arm on a pillow 
C) Help the client ambulate frequently 
D) Obtain a pneumatic compression sleeve

Question 10

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic.  Which statement by the nurse will best address these results?

Accepted Answer

A) "It is important for us to review the signs and symptoms of a hypoglycemic reaction." 
B) "Let's review your diet, exercise, and medication regimen over the past 2-3 months." 
C) "Please describe what you have eaten in the last 24-48 hours." 
D) "You should fast for at least 8 hours prior to your morning blood work."

Question 11

A parent calls the nursing triage line during the evening.  The parent says that a 7-year-old was found playing in an area with poison ivy and asks what to do.  Which is the most important instruction to give the parent?

Accepted Answer

A) Apply cool, wet compresses for itching 
B) Apply topical cortisone ointment to the area 
C) Discourage the child from scratching the area 
D) Wash the skin where the contact occurred

Question 12

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination?  Select all that apply.

Accepted Answer

A) Flank pain radiating to the groin 
B) High-protein food ingestion before the onset of pain 
C) Low-grade fever with chills 
D) Pain at the umbilicus 
E) Right upper-quadrant (RUQ) pain radiating to the right shoulder

Question 13

The nurse is caring for a client who has homonymous hemianopsia following an acute stroke.  Which nursing diagnosis is the most appropriate for this client?

Accepted Answer

A) Risk for ineffective airway maintenance 
B) Risk for knowledge deficit 
C) Risk for poor fluid intake 
D) Risk for self-neglect

Question 14

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis.  The health care provider prescribes a continuous IV infusion of nitroprusside sodium.  Which of these is the priority goal in initial management of hypertensive crisis?

Accepted Answer

A) Decrease mean arterial pressure (MAP) by no more than 25% 
B) Keep blood pressure at or below 120/80 mm Hg 
C) Maintain heart rate (HR) of 60-100/min 
D) Maintain urine output of at least 30 mL/hr

Question 15

A nurse in the emergency department cares for 4 clients with orthopedic injuries.  Which client should the nurse assess first?

Accepted Answer

A) Client who sustained a closed, incomplete ulnar fracture while playing sports 
B) Client with bilateral metacarpal fractures after falling out of bed 
C) Client with multiple myeloma who has a vertebral fracture and aching back pain 
D) Client with pain and obvious shoulder deformity reporting a "pins-and-needles" sensation

Question 16

A client comes to the emergency department in acute decompensated heart failure.  The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum.  After placing the client on oxygen via nasal cannula, which of these actions is the next priority?

Accepted Answer

A) Administer digoxin 0.25 mg 
B) Administer furosemide 40 mg IV push 
C) Initiate dopamine infusion at 5 mcg/kg/min 
D) Obtain blood sample for arterial blood gases

Question 17

The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy.  Which statement by the client requires the most immediate action by the nurse?

Accepted Answer

A) "Half of my vision looks like it's being blocked by a curtain." 
B) "I have to use reading glasses to see small print." 
C) "My vision seems cloudy and I notice a lot of glare." 
D) "The colors don't seem as bright as they used to."

Question 18

The nurse is planning discharge teaching for a client who just received a permanent pacemaker.  Which topics should the nurse include?  Select all that apply.

Accepted Answer

A) Avoid MRI scans 
B) Do not place cell phones directly over the pacemaker 
C) Notify airport security when traveling 
D) Perform shoulder range-of-motion exercises 
E) Refrain from using microwave ovens

Question 19

When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first?

Accepted Answer

A) Assess for jugular venous distension 
B) Attach the cardiac monitor to the client 
C) Auscultate heart and breath sounds 
D) Obtain the client's vital signs

Question 20

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy.  Which of the following interventions are appropriate?  Select all that apply.

Accepted Answer

A) Decrease fluid intake to 1 glass with each meal and at bedtime 
B) Encourage the client to bear down while attempting to void 
C) Inspect the perineal area for evidence of skin breakdown 
D) Measure postvoid residual volumes as prescribed 
E) Tell the client to wait 30 seconds after voiding and then attempt to void again

Exam 1: Adult Health

The nurse receives hand-off report on assigned clients. Which client should the nurse assess first?

The nurse assesses a client with a history of cystic fibrosis who is being admitted due to a pulmonary exacerbation. Which assessment finding requires immediate action by the nurse?

The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites, and esophageal varices. Which statement by the client indicates that the teaching was effective?

The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate?

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate?

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.

The emergency department nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury. Which assessment finding is consistent with injury to the occipital lobe?

A nurse is caring for a client 1 day after a left-sided mastectomy with lymph node dissection. Which nursing intervention is the priority in caring for this client?

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic. Which statement by the nurse will best address these results?

A parent calls the nursing triage line during the evening. The parent says that a 7-year-old was found playing in an area with poison ivy and asks what to do. Which is the most important instruction to give the parent?

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? Select all that apply.

The nurse is caring for a client who has homonymous hemianopsia following an acute stroke. Which nursing diagnosis is the most appropriate for this client?

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis?

A nurse in the emergency department cares for 4 clients with orthopedic injuries. Which client should the nurse assess first?

A client comes to the emergency department in acute decompensated heart failure. The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum. After placing the client on oxygen via nasal cannula, which of these actions is the next priority?

The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse?

The nurse is planning discharge teaching for a client who just received a permanent pacemaker. Which topics should the nurse include? Select all that apply.

When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first?

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate? Select all that apply.