Question 1

The nurse assesses a 40-year-old client with acromegaly in an outpatient health clinic.  Which new finding is most important to report to the health care provider?

Accepted Answer

A) Complaints of knee pain when walking 
B) Dark leathery skin 
C) Fasting blood glucose 126 mg/dL (7.0 mmol/L) 
D) Presence of S3 and S4 heart sound

Question 2

A nurse is caring for a client who developed paralytic ileus after a stroke.  The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent.  Which prescription does the nurse question?

Accepted Answer

A) Hydrocodone 5/325 mg 1 tab every 4 hours PRN for moderate pain 
B) Increase continuous IV normal saline rate from 75 to 100 mL/hr 
C) Insert nasogastric tube and attach to wall suction 
D) Ondansetron 4 mg IVP every 4 hours PRN for nausea

Question 3

The nurse is assessing a diabetic client for pain following right total knee replacement surgery.  The client reports "numbness and tingling" in the bilateral lower extremities.  Pedal pulses are strong bilaterally, and capillary refill is <3 seconds in the right great toe.  Which action should the nurse take?

Accepted Answer

A) Ask if the client wants pain medication for the "numbness and tingling" 
B) Ask the client if the "numbness and tingling" were present before surgery 
C) Continue assessment by observing the surgical dressing 
D) Notify the health care provider (HCP) immediately

Question 4

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease.  Which statements indicate a correct understanding of the instructions?  Select all that apply.

Accepted Answer

A) "I will apply moisturizing lotion on my legs every day." 
B) "I will elevate my legs at night when I am sleeping." 
C) "I will keep my legs below heart level when sitting." 
D) "I will start walking outside with my neighbor." 
E) "I will use a heating pad to promote circulation."

Question 5

A client comes to the emergency department and reports headache, nausea, and shortness of breath after being stranded at home without electricity due to severe winter weather.  While collecting a history, which question is most important for the nurse to ask?

Accepted Answer

A) "Are you up to date with your annual flu shot and other vaccinations?" 
B) "Have you had difficulty eating or drinking in the last few days?" 
C) "How have you been keeping your house warm during this weather?" 
D) "Is there anything that you have found that relieves your symptoms?"

Question 6

A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min.  IV fluids of 2-liter normal saline were administered.  Which parameters indicate that adequate rehydration has occurred?  Select all that apply.

Accepted Answer

A) Capillary refill is less than 3 seconds 
B) Pulse pressure is narrowed 
C) Systolic blood pressure drops only when standing 
D) Urine output is 360 mL in 4 hours 
E) Urine specific gravity is 1.020

Question 7

The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care and symptom management.  Which of the following client statements indicates a need for further teaching?

Accepted Answer

A) "Daily range-of-motion exercises are important to keep my joints flexible." 
B) "I can use a moist heat pack to help with joint stiffness." 
C) "I should elevate my knees with pillows when I'm sleeping." 
D) "I will make sure to rest in between activities throughout the day."

Question 8

A client is brought to the emergency department following a motor vehicle collision.  The client's admission vital signs are blood pressure 70/50 mm Hg, pulse 123/min, and respirations 8/min.  The nurse anticipates the results of which diagnostic test to bestevaluate the client's oxygenation and ventilation status?

Accepted Answer

A) Arterial blood gases 
B) Chest x-ray 
C) Hematocrit and hemoglobin levels 
D) Serum lactate level

Question 9

A client is being admitted for a potential cerebellar pathology.  Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits?  Select all that apply.

Accepted Answer

A) Identify the number "8" traced on the palm 
B) Shrug the shoulders against resistance 
C) Swallow water 
D) Touch each finger of one hand to the hand's thumb 
E) Walk heel-to-toe

Question 10

Which interventions should the nurse include when caring for a client who has had endovascular repair of an abdominal aortic aneurysm?  Select all that apply.

Accepted Answer

A) Assess abdominal incision every 4 hours 
B) Check for bleeding at groin puncture sites 
C) Measure chest tube drainage 
D) Monitor fluid intake and urine output 
E) Palpate and monitor peripheral pulses

Question 11

The nurse is obtaining a client's health history during a routine physical and wellness examination.  Which of the following statements by the client should cause the nurse to suspect potential Hodgkin lymphoma?  Select all that apply.

Accepted Answer

A) "For the past few weeks, I have noticed a pretty regular fever, but I do not have chills or feel bad." 
B) "I have had a lump in my underarm for several weeks.  I have not thought much about it because it doesn't hurt." 
C) "My weight has gone down a lot in the past month.  I have not changed my diet or exercise regimen, but it has been nice." 
D) "Recently, my skin has been very itchy.  I have had allergies in the past, but this feels different." 
E) "Sometimes when I wake up, I find I have sweat so much while sleeping that I need to change the sheets."

Question 12

An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking."  What is the priority assessment the nurse should perform?

Accepted Answer

A) Assess for dry, scaly skin on the lower legs 
B) Assess for presence or absence of hair growth on lower extremities 
C) Check for presence and quality of posterior tibial and dorsalis pedis pulses 
D) Obtain a dietary history

Question 13

A nurse is making initial client rounds at the beginning of the shift.  Which client should the nurse see first?

Accepted Answer

A) 36-year-old client with endocarditis who has a temperature of 100.6 F (38.1 
C) , chills, malaise, and a heart murmur 
B) 40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension 
C) 67-year-old client admitted for pneumonia with new-onset atrial fibrillation, who has blood pressure of 130/90 mm Hg and heart rate of 110/min 
D) 70-year-old client with advanced heart failure who is receiving intravenous (IV) diuretics, has blood pressure of 80/60 mm Hg, and is watching TV

Question 14

The nurse is caring for a client who received extracorporeal shock wave lithotripsy with ureteral stent placement for treatment of a kidney stone.  Which discharge instructions provided by the nurse are appropriate?  Select all that apply.

Accepted Answer

A) "Contact your health care provider if you develop a fever or chills." 
B) "Except for using the bathroom, you should stay on bed rest for the next 48 hours." 
C) "Increase your fluid intake to help flush out the kidney stone fragments." 
D) "It is common to have some blood in the urine up to 24 hours after this procedure." 
E) "You may develop some bruising on your back or on the side of your abdomen."

Question 15

The nurse provides care for a client diagnosed with polycythemia vera.  Which statement by the client would require immediate follow-up?

Accepted Answer

A) "I am trying to find makeup to cover my unattractive, ruddy facial complexion." 
B) "I must have injured my leg in some way.  It is sore, swollen, and red." 
C) "I take a baby aspirin to relieve my occasional headaches." 
D) "My skin itches so severely, and no lotion or cream seems to help."

Question 16

When an unlicensed assistive personnel (UAP) assists a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidently falls over and cracks.  The UAP immediately reports this incident to the nurse.  What is the nurse's immediate action?

Accepted Answer

A) Clamp the tube close to the client's chest until a new chest drainage unit is set up 
B) Notify the health care provider (HCP) 
C) Place the distal end of the chest tube into a bottle of sterile saline 
D) Position the client on the left side

Question 17

The nurse is answering questions at a hospital-sponsored health fair.  What actions should the nurse encourage to help prevent contracting the West Nile virus?  Select all that apply.

Accepted Answer

A) Avoid raw, unpeeled fruits or vegetables 
B) Limit contact with infected pets 
C) Use insect (mosquito) repellent 
D) Wash all bedding in hot water 
E) Wear long-sleeved, light-colored clothes

Question 18

The nurse educator is completing a staff education conference about prenatal carrier screening.  Which statement by a participant indicates a correct understanding of the genetic inheritance for cystic fibrosis?

Accepted Answer

A) "Both parents must be carriers of the abnormal gene for offspring to have the disorder." 
B) "Female offspring are most often affected by the inheritance pattern of cystic fibrosis." 
C) "If the female partner is a carrier, only male offspring will have the disorder." 
D) "The inheritance pattern for cystic fibrosis does not skip generations."

Question 19

A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response.  The stroke alert team is initiated.  The nurse takes which priority action?

Accepted Answer

A) Determine onset of symptoms 
B) Ensure that the client has 2 large-bore intravenous (IV) lines 
C) Maintain patent airway 
D) Prepare for head CT scan

Question 20

A nurse is teaching a nutrition class for clients with newly diagnosed type 2 diabetes.  Which meal represents the best adherence to the principles of and recommendations for diabetic meal planning?

Accepted Answer

A) Baked tilapia with tomato salsa, steamed white rice 
B) Black bean chili with brown rice, mixed green salad 
C) Grilled chicken breast with baked French fries 
D) Hamburger on a whole wheat bun with lettuce and tomato

Exam 1: Adult Health

The nurse assesses a 40-year-old client with acromegaly in an outpatient health clinic. Which new finding is most important to report to the health care provider?

A nurse is caring for a client who developed paralytic ileus after a stroke. The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent. Which prescription does the nurse question?

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.

A client comes to the emergency department and reports headache, nausea, and shortness of breath after being stranded at home without electricity due to severe winter weather. While collecting a history, which question is most important for the nurse to ask?

A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? Select all that apply.

The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care and symptom management. Which of the following client statements indicates a need for further teaching?

A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? Select all that apply.

Which interventions should the nurse include when caring for a client who has had endovascular repair of an abdominal aortic aneurysm? Select all that apply.

The nurse is obtaining a client's health history during a routine physical and wellness examination. Which of the following statements by the client should cause the nurse to suspect potential Hodgkin lymphoma? Select all that apply.

An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking." What is the priority assessment the nurse should perform?

A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first?

The nurse is caring for a client who received extracorporeal shock wave lithotripsy with ureteral stent placement for treatment of a kidney stone. Which discharge instructions provided by the nurse are appropriate? Select all that apply.

The nurse provides care for a client diagnosed with polycythemia vera. Which statement by the client would require immediate follow-up?

When an unlicensed assistive personnel (UAP) assists a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidently falls over and cracks. The UAP immediately reports this incident to the nurse. What is the nurse's immediate action?

The nurse is answering questions at a hospital-sponsored health fair. What actions should the nurse encourage to help prevent contracting the West Nile virus? Select all that apply.

The nurse educator is completing a staff education conference about prenatal carrier screening. Which statement by a participant indicates a correct understanding of the genetic inheritance for cystic fibrosis?

A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action?

A nurse is teaching a nutrition class for clients with newly diagnosed type 2 diabetes. Which meal represents the best adherence to the principles of and recommendations for diabetic meal planning?