Question 1

A client is transferred from the post-anesthesia recovery unit to the surgical unit following an open cholecystectomy.  Which interventions are most important for the nurse to perform to prevent postoperative pneumonia?  Select all that apply.

Accepted Answer

A) Administer morphine only if the pain is >8 on a 1-10 pain scale 
B) Ambulate within 8 hours after surgery, if possible 
C) Have client cough with splinting every hour 
D) Have client deep breathe and use the incentive spirometer every hour 
E) Maintain pneumatic compression devices when client is in bed
F)Place client in Fowler's position

Question 2

The nurse cares for a client with ulcerative colitis who is having abdominal pain and ?10 bloody stools per day.  Which of the following interventions should be included in the client's plan of care?  Select all that apply.

Accepted Answer

A) Administer prescribed analgesic medications as needed 
B) Encourage the client to discuss feelings about illness 
C) Initiate strict, hourly intake and output monitoring 
D) Investigate the client's compliance with the medication regimen 
E) Offer the client high-protein foods during meals and snacks

Question 3

The nurse is performing an initial assessment on a client diagnosed with Addison's disease.  Which assessment findings should the nurse anticipate?  Select all that apply.

Accepted Answer

A) Acanthosis nigricans 
B) Hirsutism 
C) Hyperpigmented skin 
D) Truncal obesity 
E) Weight loss

Question 4

The nurse is caring for a client after a lumbar puncture (spinal tap).  Which client assessment is most concerning and requires a nursing response?

Accepted Answer

A) Consumes 600 mL liquid over 4 hours 
B) Insertion site dressing saturated with clear fluid 
C) Observed lying in the right-sided Sim's position 
D) Reports a headache rated 6/10

Question 5

A client diagnosed with head and neck cancer has developed mouth sores related to external radiation therapy.  The nurse teaches the client to use which of the following oral hygiene practices?  Select all that apply.

Accepted Answer

A) Apply a water-soluble lubricating agent to moisturize mouth tissues 
B) Brush teeth with a soft-bristle toothbrush 
C) Cleanse the mouth with normal saline after meals and at bedtime 
D) Do not drink hot liquids or eat foods that are spicy or acidic 
E) Rinse with alcohol-based antiseptic mouthwash to decrease mouth odor
F)Use palifermin as prescribed to alleviate oral pain

Question 6

A self-employed auto mechanic is diagnosed with carbon monoxide poisoning.  Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air.  What is the nurse's priority action?

Accepted Answer

A) Administer 5 mg inhaled albuterol nebulizer treatment to decrease inflammatory bronchoconstriction 
B) Administer 100% oxygen using a nonrebreather mask with flow rate of 15 L/min 
C) Administer methylprednisolone to decrease lung inflammation from toxic inhalant 
D) Titrate oxygen to maintain pulse oximeter saturation of >95%

Question 7

The nurse prepares to administer a dose of radioactive iodine (RAI) to a 39-year-old female client with Graves' disease.  Which action is most important for the nurse to take?

Accepted Answer

A) Ask client when her last menstrual cycle occurred 
B) Confirm pregnancy test result is negative 
C) Obtain a baseline assessment of the mouth and throat 
D) Teach the client the signs and symptoms of hypothyroidism

Question 8

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery.  During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm.  What action should the nurse take?

Accepted Answer

A) Anticipate the scheduling of a biopsy 
B) Apply ice to the node 
C) Reassure the client that it is an expected finding 
D) Request an antibiotic

Question 9

The charge nurse is making rounds and should immediately intervene when making which observation?

Accepted Answer

A) A new nurse is using gentle pressure to flush a kidney pelvis catheter with 5 mL of fluid 
B) A nursing assistant is hanging a urinary drainage bag on the back of a wheelchair when transporting a client 
C) Indwelling urinary catheter is taped to a male client's inner thigh 
D) Total oral fluid intake in 24 hours for a client with a urinary diversion device is 2,800 mL

Question 10

The nurse is caring for a client following a transsphenoidal hypophysectomy.  Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus?  Select all that apply.

Accepted Answer

A) Decreased serum sodium 
B) Excess oral water intake 
C) High urine output 
D) Increased serum osmolality 
E) Increased urine specific gravity

Question 11

The nurse cares for a client with an exacerbation of inflammatory bowel disease (IBD).  The client tells the nurse about being infected with tuberculosis (TB) 10 years ago but never being medicated.  Which prescription is of concern and prompts the nurse to notify the health care provider (HCP)?

Accepted Answer

A) Lansoprazole 
B) Metronidazole 
C) Prednisone 
D) Sulfasalazine

Question 12

The clinic nurse is completing a health history for a client with suspected rheumatic fever (RF).  Which question is most important for the nurse to ask to establish a diagnosis?

Accepted Answer

A) "Do you typically take all your antibiotics when they are prescribed?" 
B) "Has anyone in your family had rheumatic fever?" 
C) "Have you recently had a streptococcal throat infection?" 
D) "What has your temperature been over the past several days?"

Question 13

The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client who has had multiple long bone fractures.  Which findings does the nurse expect to assess to support this diagnosis?  Select all that apply.

Accepted Answer

A) Confusion and restlessness 
B) Increasing pain despite the opioid analgesia 
C) Paresthesia of the affected extremity 
D) Petechiae over neck and chest 
E) Pulse oximeter showing hypoxia

Question 14

The nurse is giving report to a licensed practical nurse (LPN) who will be helping to monitor a client who just had a total thyroidectomy.  What will the nurse emphasize as most important to report immediately?

Accepted Answer

A) Elevated blood pressure 
B) Heart rate irregularity 
C) Low oxygen saturation 
D) Noisy breathing

Question 15

The nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes.  Which cranial nerves is the nurse assessing?  Select all that apply.

Accepted Answer

A) II 
B) III 
C) IV 
D) V 
E) VI

Question 16

The nurse assesses a client who had a thyroidectomy 8 hours ago.  The nurse finds the client anxious, with tingling around the mouth and muscle twitching in the right arm.  Which action is most important for the nurse to implement first?

Accepted Answer

A) Change the surgical dressing to assess for bleeding 
B) Document the findings in the electronic medical record 
C) Draw arterial blood gases 
D) Obtain a serum calcium level

Question 17

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment.  Which actions should the nurse take to prepare the client for hemodialysis?  Select all that apply.

Accepted Answer

A) Administer subcutaneous heparin to decrease clotting during dialysis 
B) Administer the client's morning doses of carvedilol and lisinopril 
C) Check the client's medical records to determine the last post-dialysis weight 
D) Obtain a set of client vital signs and the client's current weight 
E) Palpate the fistula in the client's arm for a thrill and auscultate for a bruit

Question 18

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes.  Status epilepticus is suspected.  Which nursing intervention should be performed first?

Accepted Answer

A) Administer rectal diazepam 
B) Assess for neck stiffness and Brudzinski sign 
C) Draw blood for laboratory studies 
D) Transport the client to CT for assessment of shunt malfunction

Question 19

A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away.  How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal?

Accepted Answer

A) 450 kcal/day 
B) 625 kcal/day 
C) 860 kcal/day 
D) 1,000 kcal/day

Question 20

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis.  The client has oliguria, dark amber urine, and muscle pain.  The nurse should implement which prescription first?

Accepted Answer

A) ECG 
B) IV morphine 2 mg 
C) Normal saline bolus 
D) Urine sample

Exam 1: Adult Health

A client is transferred from the post-anesthesia recovery unit to the surgical unit following an open cholecystectomy. Which interventions are most important for the nurse to perform to prevent postoperative pneumonia? Select all that apply.

The nurse cares for a client with ulcerative colitis who is having abdominal pain and ?10 bloody stools per day. Which of the following interventions should be included in the client's plan of care? Select all that apply.

The nurse is performing an initial assessment on a client diagnosed with Addison's disease. Which assessment findings should the nurse anticipate? Select all that apply.

The nurse is caring for a client after a lumbar puncture (spinal tap) . Which client assessment is most concerning and requires a nursing response?

A client diagnosed with head and neck cancer has developed mouth sores related to external radiation therapy. The nurse teaches the client to use which of the following oral hygiene practices? Select all that apply.

A self-employed auto mechanic is diagnosed with carbon monoxide poisoning. Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. What is the nurse's priority action?

The nurse prepares to administer a dose of radioactive iodine (RAI) to a 39-year-old female client with Graves' disease. Which action is most important for the nurse to take?

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery. During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm. What action should the nurse take?

The charge nurse is making rounds and should immediately intervene when making which observation?

The nurse is caring for a client following a transsphenoidal hypophysectomy. Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus? Select all that apply.

The nurse cares for a client with an exacerbation of inflammatory bowel disease (IBD) . The client tells the nurse about being infected with tuberculosis (TB) 10 years ago but never being medicated. Which prescription is of concern and prompts the nurse to notify the health care provider (HCP) ?

The clinic nurse is completing a health history for a client with suspected rheumatic fever (RF) . Which question is most important for the nurse to ask to establish a diagnosis?

The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client who has had multiple long bone fractures. Which findings does the nurse expect to assess to support this diagnosis? Select all that apply.

The nurse is giving report to a licensed practical nurse (LPN) who will be helping to monitor a client who just had a total thyroidectomy. What will the nurse emphasize as most important to report immediately?

The nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes. Which cranial nerves is the nurse assessing? Select all that apply.

The nurse assesses a client who had a thyroidectomy 8 hours ago. The nurse finds the client anxious, with tingling around the mouth and muscle twitching in the right arm. Which action is most important for the nurse to implement first?

A client diagnosed with end-stage renal disease comes to the dialysis clinic for treatment. Which actions should the nurse take to prepare the client for hemodialysis? Select all that apply.

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first?

A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away. How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal?

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and muscle pain. The nurse should implement which prescription first?