Question 1

The nurse is gathering data on a client with obstructive sleep apnea.  Which findings are consistent with this client's diagnosis?  Select all that apply.

Accepted Answer

A) Difficulty arousing from sleep 
B) Excessive daytime sleepiness 
C) Morning headaches 
D) Postural collapse and falling 
E) Snoring during sleep
F)Witnessed episodes of apnea

Question 2

The clinic nurse evaluates the treatment plan of a client with long-standing rheumatoid arthritis.  Which question is most important for the nurse to ask?

Accepted Answer

A) "Have the assistive devices helped with dressing and grooming?" 
B) "How do you feel about the changes in your appearance?" 
C) "How is your pain control with the current medication regimen?" 
D) "Is your level of energy adequate for completing your daily activities?"

Question 3

The nurse reinforces the physical therapist's teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee.  Which client statement indicates the need for further teaching?

Accepted Answer

A) "I will hold the cane in my right hand." 
B) "I will move my left leg forward after moving the cane." 
C) "I will place the cane several inches in front of and to the side of my right foot." 
D) "My cane should equal the distance from my waist to the floor."

Question 4

A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago.  Which intervention should the nurse implement first?

Accepted Answer

A) Administer prescribed analgesic medication for incisional pain 
B) Encourage use of incentive spirometer every 2 hours while awake 
C) Offer an additional pillow to splint the incision while coughing 
D) Promote increased oral fluid intake

Question 5

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia.  The nurse notes an oxygen saturation of 88%.  Which is the most appropriate initial intervention?

Accepted Answer

A) Assess pupillary response 
B) Auscultate lung sounds 
C) Inform anesthesia professional 
D) Perform head tilt and chin lift

Question 6

The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident.  The drainage has been consistently 25-50 mL/hr for the majority of the shift.  However, over the past 2 hours there has been no drainage.  Which actions should the nurse take?  Select all that apply.

Accepted Answer

A) Auscultate breath sounds 
B) Increase amount of suction 
C) Instruct client to cough and deep breathe 
D) Milk the chest tube 
E) Reposition the client

Question 7

A nurse is reinforcing teaching with a client newly diagnosed with human immunodeficiency virus (HIV) about actions to prevent complications.  Which of the following statements indicate that teaching was effective?  Select all that apply.

Accepted Answer

A) "I should ask for my steak to be cooked thoroughly with no pink." 
B) "I should receive the influenza vaccine every year." 
C) "I will ask my roommate to change the cat litter box for me." 
D) "If I travel to a developing country, I will use bottled water when brushing my teeth." 
E) "If my HIV viral load is undetectable, I do not need to wear condoms."

Question 8

The nurse is caring for a client with suspected pelvic inflammatory disease (PID).  When the nurse is obtaining the client's health history, which of the following questions would provide pertinent data about the client's risk factors for PID?  Select all that apply.

Accepted Answer

A) "Are you currently taking oral contraceptives?" 
B) "At what age did you experience your first menstrual cycle?" 
C) "Do you engage in sexual intercourse with multiple partners?" 
D) "Have you ever been diagnosed with a sexually transmitted infection?" 
E) "Have you recently had an abortion or pelvic surgery?"

Question 9

The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension.  What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)?

Accepted Answer

A) Consume a low-fat, low-salt diet 
B) Do not smoke cigarettes 
C) Exercise and lose weight 
D) Take prescribed antihypertensive medications

Question 10

The nurse assesses a client diagnosed with chronic kidney disease who had an internal arteriovenous fistula performed on the left arm yesterday.  Which assessment finding would require immediate follow-up?

Accepted Answer

A) A bruit cannot be auscultated over the fistula site 
B) Capillary refill of 2 seconds is assessed on the left hand 
C) Client reports squeezing a rubber ball with the left hand several times daily 
D) Incision is dry with no redness and has sterile skin closures in place

Question 11

The nurse is caring for a client on the organ donation waiting list for cardiac transplantation.  Which teaching topic is most important for the nurse to emphasize at this time?

Accepted Answer

A) Immunosuppressive therapy as a lifelong commitment 
B) Importance of accurate daily weight monitoring 
C) Importance of periodic endomyocardial biopsies 
D) Maintenance of meticulous surgical incision care

Question 12

A client has potential radiation contamination from a disaster.  The nurse should monitor for which of the following related to this contamination?  Select all that apply.

Accepted Answer

A) Bitter almond smell on breath 
B) Fever and raised skin pustules 
C) Low blood cell counts 
D) Oral mucosal ulcerations 
E) Vomiting and diarrhea

Question 13

The nurse in the outpatient procedure unit is caring for a client immediately post bronchoscopy.  Which assessment data indicate that the nurse needs to contact the health care provider immediately?

Accepted Answer

A) Absence of gag reflex 
B) Bright red blood mixed with sputum 
C) Headache 
D) Respirations 10/min and saturation of 92%

Question 14

A home health nurse visits a client with chronic obstructive pulmonary disease.  The nurse teaches the client to use abdominal breathing to perform the "huff" cough technique to facilitate secretion removal.  Place the steps in the correct order.  All options must be used.

Accepted Answer

A) "Hold your breath for 2-3 seconds and then forcefully exhale quickly." 
B) "Perform a slow, deep inhalation with your mouth using your diaphragm." 
C) "Repeat the huff once or twice more, while refraining from performing a normal cough." 
D) "Rest for 5-10 normal breaths and repeat as necessary until mucus is cleared." 
E) "Sit upright in a chair with feet spread shoulder-width apart and lean forward."

Question 15

A client has an allergy skin test that is positive for dust mites.  The nurse provides instruction on environmental interventions the client can use to control symptoms by reducing exposure to this allergen.  Which intervention would be described in this teaching?

Accepted Answer

A) Allergy shots or sublingual immunotherapy 
B) Antihistamine use 
C) Vacuum carpeting once a week 
D) Wash bed linens in hot water once a week

Question 16

The nurse cares for a transgender client who is prescribed estrogen therapy.  Which side effect is most important for the nurse to report to the health care provider?

Accepted Answer

A) Breast tenderness 
B) Generalized weight gain 
C) Leg swelling 
D) Nausea and vomiting

Question 17

A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days.  Which information is most important for the nurse to ask this client?

Accepted Answer

A) Diet recall for this current week 
B) Fluid intake for the past 2 days 
C) Medications and dosages taken over the past 2 days 
D) Presence of shortness of breath, coughing, or edema

Question 18

The nurse is caring for a client diagnosed with influenza who has had high fever, muscle aches, headache, and sore throat for 36 hours.  The health care provider prescribes ibuprofen and oseltamivir.  Which of the following actions by the nurse are appropriate?  Select all that apply.

Accepted Answer

A) Clarify the prescription for oseltamivir with the health care provider 
B) Instruct the client to cover the mouth and nose while coughing or sneezing 
C) Place a mask on the client when transporting the client through the halls 
D) Plan discharge teaching about the importance of annual influenza vaccination 
E) Use contact precautions when providing care for the client

Question 19

A client with chest pain is diagnosed with acute pericarditis by the health care provider.  The nurse explains that the pain will improve with which of the following?

Accepted Answer

A) Coughing and deep breathing 
B) Left lateral position 
C) Pursed-lip breathing 
D) Sitting up and leaning forward

Question 20

The nurse working on an orthopedic unit is receiving report on 4 clients with recent fractures.  Which client should the nurse assess first?

Accepted Answer

A) Client who has a femur fracture with a rash of pin-sized red spots on the chest and increased restlessness 
B) Client who has purulent drainage oozing from a skeletal traction pin insertion site and a temperature of 100.8 F (38.2 
C)  
C) Client with a hip fracture receiving continuous IV saline with bilateral 2+ pitting leg edema and a blood pressure of 176/89 mm Hg 
D) Client with a rib fracture who is breathing at a rate of 23/min and is reporting 8/10 pain that is worse with inspiration

Exam 1: Adult Health

The nurse is gathering data on a client with obstructive sleep apnea. Which findings are consistent with this client's diagnosis? Select all that apply.

The clinic nurse evaluates the treatment plan of a client with long-standing rheumatoid arthritis. Which question is most important for the nurse to ask?

The nurse reinforces the physical therapist's teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee. Which client statement indicates the need for further teaching?

A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first?

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention?

A nurse is reinforcing teaching with a client newly diagnosed with human immunodeficiency virus (HIV) about actions to prevent complications. Which of the following statements indicate that teaching was effective? Select all that apply.

The nurse is caring for a client with suspected pelvic inflammatory disease (PID) . When the nurse is obtaining the client's health history, which of the following questions would provide pertinent data about the client's risk factors for PID? Select all that apply.

The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack) ?

The nurse assesses a client diagnosed with chronic kidney disease who had an internal arteriovenous fistula performed on the left arm yesterday. Which assessment finding would require immediate follow-up?

The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time?

A client has potential radiation contamination from a disaster. The nurse should monitor for which of the following related to this contamination? Select all that apply.

The nurse in the outpatient procedure unit is caring for a client immediately post bronchoscopy. Which assessment data indicate that the nurse needs to contact the health care provider immediately?

A home health nurse visits a client with chronic obstructive pulmonary disease. The nurse teaches the client to use abdominal breathing to perform the "huff" cough technique to facilitate secretion removal. Place the steps in the correct order. All options must be used.

A client has an allergy skin test that is positive for dust mites. The nurse provides instruction on environmental interventions the client can use to control symptoms by reducing exposure to this allergen. Which intervention would be described in this teaching?

The nurse cares for a transgender client who is prescribed estrogen therapy. Which side effect is most important for the nurse to report to the health care provider?

A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days. Which information is most important for the nurse to ask this client?

The nurse is caring for a client diagnosed with influenza who has had high fever, muscle aches, headache, and sore throat for 36 hours. The health care provider prescribes ibuprofen and oseltamivir. Which of the following actions by the nurse are appropriate? Select all that apply.

A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following?

The nurse working on an orthopedic unit is receiving report on 4 clients with recent fractures. Which client should the nurse assess first?