Adult Nursing Exam 3
A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement would the nurse include when delegating care for a patient with cranial nerve II impairment? a."Assist the patient by placing the fork in the left hand." b."Tell the patient where food items are on the breakfast tray." c."Make sure the patient's food is visually appetizing." d."Place the patient in a high-Fowler's position for all meals."
B. "Tell the patient where food items are on the breakfast tray"
A nurse assesses a patient and notes the patient's position as indicated in the illustration below: How would the nurse document this finding? a.Atypical hyperreflexia b.Decorticate posturing c.Spinal cord degeneration d.Decerebrate posturing
B. Decorticate Posturing
A postoperative patient is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the patient? (Select all that apply.) a."Do not take more pills each day than you are prescribed." b."If this gives you diarrhea, loperamide (Imodium) can help." c."Eat a diet that is high in fiber and drink lots of water." d."You shouldn't drive while you are taking this medication." e."Check all over-the-counter medications for acetaminophen."
a."Do not take more pills each day than you are prescribed." c."Eat a diet that is high in fiber and drink lots of water." d."You shouldn't drive while you are taking this medication." e."Check all over-the-counter medications for acetaminophen."
A student nurse asks what "essential hypertension" is. What response by the registered nurse is best? a."It is hypertension with no specific cause." b."It refers to severe and life-threatening hypertension." c."It means it is caused by another disease." d."It means it is 'essential' that it be treated."
a."It is hypertension with no specific cause."
A nurse in a family practice clinic is preparing discharge instructions for a patient reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a."Try warm, moist heat packs on your face." b."Limit fluids to dry out your sinuses." c."Ice packs may help with the facial pain." d."We will schedule you for a computed tomography scan this week."
a."Try warm, moist heat packs on your face."
A nurse is giving a client instructions for showering the night before surgery. What instruction is most appropriate? a."Use the prescribed solution and wash the area where you will have surgery very thoroughly." b."Use warm water and scrub the surgical area vigorously." c."Use a washcloth to wash the surgical site; do not take a full shower or bath." d."After you wash the surgical site, shave that area with your own razor."
a."Use the prescribed solution and wash the area where you will have surgery very thoroughly."
A nurse cares for a patient who is recovering from a myocardial infarction. The patient states, "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response? a."What do you understand about what happened to you?" b."Chili is high in fat and calories; it would be a good idea to stop eating it." c."The provider has prescribed an antacid for you to take every morning." d."When did you start experiencing this indigestion?"
a."What do you understand about what happened to you?"
A nurse assesses several patients who have a history of asthma. Which patient would the nurse assess first? a.A 27-year-old patient with a heart rate of 120 beats/min b.A 35-year-old patient who has a longer expiratory phase than inspiratory phase c.A 48-year-old patient with an oxygen saturation level of 92% at rest d.A 66-year-old patient with a barrel chest and clubbed fingernails
a.A 27-year-old patient with a heart rate of 120 beats/min
A postoperative nurse is caring for a patient who receives a neuromuscular blocking agent during surgery. Which assessment by the nurse is most important? a.Abdominal breathing pattern b.Blood pressure within 20 points of preanesthetic level c.Weak hand grasp d.Inability to raise head off the bed
a.Abdominal breathing pattern
A nurse assesses a patient who is scheduled for a cardiac catheterization. Which assessment would the nurse complete prior to this procedure? a.Allergies to iodine-based agents b.Ability to turn self in bed c.Patient's level of anxiety d.Cardiac rhythm and heart rate
a.Allergies to iodine-based agents
A nurse plans care for a patient who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this patient's plan of care? (Select all that apply.) a.Ask the patient to drink 2 L of fluids daily. b.Add humidity to the prescribed oxygen. c.Suction the patient every 2 to 3 hours. d.Use a vibrating positive expiratory pressure device. e.Encourage diaphragmatic breathing.
a.Ask the patient to drink 2 L of fluids daily. b.Add humidity to the prescribed oxygen. d.Use a vibrating positive expiratory pressure device.
An emergency room nurse assesses a female patient. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram?(Select all that apply.) a.Indigestion b.Hypertension c.Shortness of breath d.Fatigue despite adequate rest e.Abdominal pain
a.Indigestion c.Shortness of breath d.Fatigue despite adequate rest
A nurse assesses a patient who has aortic regurgitation. In which location in the illustration shown below would the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a.Location A b.Location B c.Location C d.Location D
a.Location A
A nurse reviews a patient's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis?(Select all that apply.) a.Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L) b.Serum albumin: 4 g/dL (5.8 mcmol/L) c.Triglycerides: 200 mg/dL (2.3 mmol/L) d.High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L) e.Total cholesterol: 280 mg/dL (7.3 mmol/L)
a.Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L) c.Triglycerides: 200 mg/dL (2.3 mmol/L) e.Total cholesterol: 280 mg/dL (7.3 mmol/L)
A patient has arrived in the inpatient postoperative unit. What action by the inpatient nurse takes priority? a.Participating in hand-off report b.Assessing fluid and blood output c.Checking the surgical dressings d.Ensuring the patient is warm
a.Participating in hand-off report
A nurse cares for a client who has Alzheimer's disease. Which communication techniques would the nurse implement? (Select all that apply.) a.Pictures with instructions b.Open-ended questions c.Gestures when speaking d.Multiple choices e.Validate client feelings
a.Pictures with instructions c.Gestures when speaking e.Validate client feelings
A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition would alert the nurse to hold the medication and contact the healthcare provider? a.Prinzmetal's angina b.Chronic kidney disease c.Diabetes mellitus d.Bronchial asthma
a.Prinzmetal's angina
A nurse assesses a patient after administering a prescribed beta-blocker. Which assessment would the nurse expect to find? a.Pulse decreased from 100 to 80 beats/min b.Blood pressure increased from 98/42 to 132/60 mm Hg c.Respiratory rate decreased from 25 to 14 breaths/min d.Oxygen saturation increased from 88% to 96%
a.Pulse decreased from 100 to 80 beats/min
A nurse assesses a patient after a thoracentesis. Which assessment finding warrants immediate action? a.The trachea is deviated toward the opposite side of the neck. b.The patient rates pain as a 5/10 at the site of the procedure. c.Pulse oximetry is 93% on 2 L of oxygen. d.A small amount of drainage from the site is noted.
a.The trachea is deviated toward the opposite side of the neck.
A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered to be at high risk? (Select all that apply.) a.Wheelchair-bound client b.Client with severe heart failure c.Client with a humerus fracture d.Morbidly obese client e.Client who smokes
a.Wheelchair-bound client b.Client with severe heart failure d.Morbidly obese client e.Client who smokes
A nurse is teaching a patient with cerebellar function impairment. Which statement would the nurse include in this patient's discharge teaching? a."Use a natural gas detector with an audible alarm." b."Ask a friend to drive you to your follow-up appointments." c."Label your faucet knobs with hot and cold signs." d."Connect a light to flash when your door bell rings."
b."Ask a friend to drive you to your follow-up appointments."
A nurse teaches a patient who is interested in smoking cessation. Which statements would the nurse include in this patient's teaching? (Select all that apply.) a."Identify a punishment for yourself in case you backslide." b."Find an activity that you enjoy and will keep your hands busy." c."Drink at least eight glasses of water each day." d."Make a list of reasons you want to stop smoking." e."Keep snacks like potato chips on hand to nibble on."
b."Find an activity that you enjoy and will keep your hands busy." c."Drink at least eight glasses of water each day." d."Make a list of reasons you want to stop smoking."
A nurse witnesses a client with late-stage Alzheimer's disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." How would the nurse respond? a."Your family will be here soon. Let's get you dressed." b."I see you are still hungry. I will get you some toast." c."You ate your breakfast 30 minutes ago." d."It appears you are confused this morning."
b."I see you are still hungry. I will get you some toast."
An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The patient is afebrile. The healthcare provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a."Chest x-rays are always ordered when we suspect pneumonia." b."Older people often have vague symptoms, so an x-ray is essential." c."We are testing for any possible source of infection in the patient." d."The x-ray can be done and read before laboratory work is reported."
b."Older people often have vague symptoms, so an x-ray is essential."
The nurse instructs a patient on how to correctly use an inhaler with a spacer. In which order would these steps occur? 1. "Press down firmly on the canister to release one dose of medication." 2. "Breathe in slowly and deeply." 3. "Shake the whole unit vigorously three or four times." 4. "Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer." 5. "Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece." 6. "Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds." a.2, 3, 4, 5, 6, 1 b.4, 3, 5, 1, 2, 6 c.3, 4, 5, 1, 6, 2 d.5, 3, 6, 1, 2, 4
b.4, 3, 5, 1, 2, 6
A nurse assesses patients on a medical-surgical unit. Which patient would the nurse identify as having the greatest risk for cardiovascular disease? a.A 53-year-old postmenopausal woman who is on hormone therapy b.A 45-year-old American Indian woman with diabetes mellitus c.An 86-year-old man with a history of asthma d.A 32-year-old Asian-American man with colorectal cancer
b.A 45-year-old American Indian woman with diabetes mellitus
A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience would the nurse provide this service? a.High school sports camps b.African-American churches c.Asian-American groceries d.Women's health clinics
b.African-American Churches
A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a.Breathing b.Airway c.Cardiac rhythm d.Bleeding
b.Airway
A nurse assesses a patient 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take? a.Document the finding as "left pedal pulse of +1/4." b.Assess the color and temperature of the left leg. c.Increase the flow rate of intravenous fluids. d.Elevate the leg and apply a sandbag to the entrance site.
b.Assess the color and temperature of the left leg.
A nurse cares for a patient who had a bronchoscopy 2 hours ago. The patient asks for a drink of water. What action would the nurse take next? a.Provide the patient with ice chips instead of a drink of water. b.Assess the patient's gag reflex before giving any food or water. c.Call the physician and request a prescription for food and water. d.Let the patient have a small sip to see whether he or she can swallow.
b.Assess the patient's gag reflex before giving any food or water.
The nurse is evaluating a 3-day diet history with a patient who has an elevated lipid panel. What meal selection indicates that the patient is managing this condition well with diet? a.Fried catfish, cornbread, peas b.Baked chicken breast, broccoli, tomatoes c.A 4-ounce steak, French fries, iceberg lettuce d.Spaghetti with meat sauce, garlic bread
b.Baked chicken breast, broccoli, tomatoes
A postoperative patient has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer? a.Naloxone (Narcan) 4 to 20 mg b.Flumazenil (Romazicon) 0.2 to 1 mg c.Flumazenil (Romazicon) 2 to 10 mg d.Naloxone (Narcan) 0.4 to 2 mg
b.Flumazenil (Romazicon) 0.2 to 1 mg
The nurse is caring for four hypertensive patients. Which drug-laboratory value combination would the nurse report immediately to the healthcare provider? a.Spironolactone (Aldactone)/potassium: 5.1 mEq/L b.Furosemide (Lasix)/potassium: 2.1 mEq/L c.Torsemide (Demadex)/sodium: 142 mEq/L d.Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L
b.Furosemide (Lasix)/potassium: 2.1 mEq/L
The nurse is caring for a client with lower extremity peripheral arterial disease (PAD). Which statement made by the client regarding self-management requires further health teaching? [Select all that apply] a.I will avoid crossing my legs at all times. b.I will elevate my legs above the level of my heart. c.I will use a heating pad to promote circulation. d.I need to quit smoking as soon as I can.
b.I will elevate my legs above the level of my heart. c.I will use a heating pad to promote circulation.
A nurse answers a call light on the postoperative nursing unit. The patient states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action does the nurse take first? a.Assess the patient's blood pressure. b.Perform hand hygiene and apply gloves. c.Reinforce the dressing with a clean one. d.Remove the dressing to assess the wound.
b.Perform hand hygiene and apply gloves.
After teaching a patient how to perform diaphragmatic breathing, the nurse assesses the patient's understanding. Which action demonstrates that the patient correctly understands the teaching? a.The patient places his or her hands above his or her head. b.The patient places his or her hands on his or her abdomen. c.The patient lays in a prone position with his or her legs straight. d.The patient lays on his or her side with his or her knees bent.
b.The patient places his or her hands on his or her abdomen.
A nurse assesses a client who has Parkinson disease. Which manifestations would the nurse recognize as a key feature of this disease? (Select all that apply.) a.Tachycardia b.Uncontrolled drooling c.Flexed trunk d.Slow movements e.Long, extended steps
b.Uncontrolled drooling c.Flexed trunk d.Slow movements
A nurse obtains a focused health history for a patient who is scheduled for magnetic resonance angiography. Which priority question would the nurse ask before the test? a."Have you had a recent blood transfusion?" b."Do you currently use oral contraceptives?" c."Do you have allergies to iodine or shellfish?" d. "Are you taking any cardiac medications?"
c. "Do you have allergies to iodine or shellfish?"
A nurse cares for a client with advanced Alzheimer's disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" How would the nurse respond? a."This is a sign of fatigue. The client would benefit from a daily nap." b."The provider can prescribe a mild sedative for restlessness." c."Engage the client in scheduled activities throughout the day." d."It sounds like this is difficult for you. I will consult the social worker."
c. "Engage the client in scheduled activities throughout the day."
A patient admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the patient questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a."Everyone with pneumonia is dehydrated." b."This is really just to administer your antibiotics." c."Breathing so quickly can be dehydrating." d."Why do you think you are so dehydrated?"
c."Breathing so quickly can be dehydrating."
After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease? a."He should not socialize outside of the house due to uncontrollable drooling." b."His masklike face makes it difficult to communicate, so I will use a white board." c."He may have trouble chewing, so I will offer bite-sized portions." d."This disease is associated with anxiety causing increased perspiration."
c."He may have trouble chewing, so I will offer bite-sized portions."
A nurse prepares to discharge a client with Alzheimer's disease. Which statement would the nurse include in the discharge teaching for this client's caregiver? a."Allow the client to rest most of the day." b."Provide a high-calorie and high-protein diet." c."Install deadbolt locks on all outside doors." d."Place a padded throw rug at the bedside."
c."Install deadbolt locks on all outside doors."
A patient has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a."Do you have trouble affording your medications?" b."You are lucky; most people get severe morning headaches." c."Most people with hypertension do not have symptoms." d."You need to take your medicine or you will get kidney failure."
c."Most people with hypertension do not have symptoms."
A nurse is teaching a larger female patient about alcohol intake and how it affects hypertension. The patient asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a."Yes, since you are larger, you can have more alcohol." b."Yes, two beers per day is an acceptable amount of alcohol." c."No, women should only have one beer a day as a general rule." d."No, you should not drink any alcohol with hypertension."
c."No, women should only have one beer a day as a general rule."
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta-blocker. Which statement would the nurse include in this client's teaching? a."This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines." b."This drug will relieve the pain during the aura phase soon after a headache has started." c."Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches." d."Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache."
c."Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches."
A nurse prepares a patient for coronary cardiac catheterization surgery. The patient states, "I am afraid I might die." What is the nurse's best response? a."What support systems do you have to assist you?" b."This is a routine test and the risk of death is very low." c."Tell me more about your concerns about the test." d."Would you like to speak with a chaplain prior to test?"
c."Tell me more about your concerns about the test."
A nurse teaches a patient with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition would the nurse include in this patient's teaching? a."If you exercise more frequently, you won't need to change your diet." b."The best way to lose weight is a high-protein, low-carbohydrate diet." c."You should balance weight loss with consuming necessary nutrients." d."A nutritionist will provide you with information about your new diet."
c."You should balance weight loss with consuming necessary nutrients."
A postoperative patient has just been admitted to the post-anesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a.Cardiac rhythm b.Bleeding c.Airway d.Breathing
c.Airway
A nurse assesses a patient in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a.Document the findings thoroughly in the patient's chart. b.Encourage the patient to eat more after recovering from surgery. c.Consult the surgeon about a postoperative dietitian referral. d.Refer the patient to Meals on Wheels after discharge.
c.Consult the surgeon about a postoperative dietitian referral.
A nurse auscultates a harsh hollow sound over a patient's trachea and larynx. What action would the nurse take first? a.Position the patient in high-Fowler's position. b.Administer prescribed albuterol. c.Document the findings. d.Administer oxygen therapy.
c.Document the findings.
A nurse obtains a focused health history for a patient who is scheduled for magnetic resonance imaging (MRI). Which condition would alert the nurse to contact the provider and cancel the procedure? a.Blood urea nitrogen (BUN) of 50 mg/dL (17.8 mmol/L) b.Atrioventricular graft c.Internal insulin pump d.Creatine phosphokinase (CPK) of 100 IU/L
c.Internal insulin pump
A preoperative nurse is reviewing morning laboratory values on four patients waiting for surgery. Which result warrants immediate communication with the surgical team? a.Creatinine: 1.2 mg/dL(106.1 umol/l) b.Sodium: 134 mEq/L (134 mmol/l) c.Potassium: 2.9 mEq/L (2.9 mmol/l) d.Hemoglobin: 14.8 mg/dL (148 mmol/L)
c.Potassium: 2.9 mEq/L (2.9 mmol/l)
A nurse cares for a patient with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first? a."What do you understand about your disease?" b."What medications are you prescribed to take each day?" c."Do you have a strong support system?" d."Do you experience shortness of breath with basic activities?"
d."Do you experience shortness of breath with basic activities?"
A nurse observes that a patient's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the patient in response to this finding? a."How often do you perform aerobic exercise?" b."What is your occupation and what are your hobbies?" c."Are you taking any medications or herbal supplements?" d."Do you have any chronic breathing problems?"
d."Do you have any chronic breathing problems?"
A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a."Be sure you keep all your postoperative appointments." b."Eat a diet high in protein, iron, zinc, and vitamin C." c."Call your surgeon if you have any questions at home." d."Wash your hands before touching the drain or dressing."
d."Wash your hands before touching the drain or dressing."
A nurse is assessing a patient who is recovering from a lung biopsy. Which assessment finding requires immediate action? a.Increased temperature b.Incisional discomfort c.Productive cough d.Absent breath sounds
d.Absent breath sounds
A patient had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a.Clean technique when changing dressings b.Monitoring the patient's daily white blood cell count c.Assessing the patient's temperature every 4 hours d.Appropriate hand hygiene before giving care
d.Appropriate hand hygiene before giving care
A patient has been diagnosed with a deep-vein thrombosis and is to be discharged on warfarin (Coumadin). The patient is adamant about refusing the drug because "it's dangerous." What action by the nurse is best? a.Warn the patient about consequences of noncompliance. b.Tell the patient that drugs are safer today than before. c.Remind the patient about laboratory monitoring. d.Assess the reason behind the patient's fear.
d.Assess the reason behind the patient's fear.
A nurse is caring for a postoperative patient who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a.Have the patient sit up in a recliner. b.Assess the patient's pain on a 0-to-10 scale. c.Tell the patient when pain medication is due. d.Assist the patient into a position of comfort.
d.Assist the patient into a position of comfort.
An older patient is hospitalized after an operation. When assessing the patient for postoperative infection, the nurse places priority on which assessment? a.Daily white blood cell count b.Tolerance of increasing activity c.Presence of fever and chills d.Change in behavior
d.Change in behavior
A nurse assesses a patient who is prescribed fluticasone (Flovent) and notes oral lesions. What action would the nurse take? a.Document the finding as a known side effect. b.Start the patient on a broad-spectrum antibiotic. c.Obtain an oral specimen for culture and sensitivity. d.Encourage oral rinsing after fluticasone administration.
d.Encourage oral rinsing after fluticasone administration.
A nurse works on the postoperative floor and has four patients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the healthcare team for postdischarge care? a.Middle-aged patient who is post-knee replacement, and needs physical therapy b.Married young adult who is the primary caregiver for children c.Young patient who lives alone, and has family and friends nearby d.Older adult who lives at home despite some memory loss
d.Older adult who lives at home despite some memory loss
A nursing student is caring for a patient with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a.Measures the abdominal girth b.Auscultates over abdominal bruit c.Assesses the patient for back pain d.Palpates the abdomen in four quadrants
d.Palpates the abdomen in four quadrants
A nurse prepares a patient for lumbar puncture (LP). Which assessment finding would alert the nurse to contact the healthcare provider? a.Paroxysmal nocturnal dyspnea b.Patient is claustrophobic c.Absence of intravenous access d.Shingles on the patient's back
d.Shingles on the patient's back
A nurse performs an assessment of pain discrimination on an older adult patient. The patient correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action would the nurse take next? a.Contact the provider with the assessment results. b.Continue the assessment on the patient's feet. c.Ask the patient about current medications. d.Touch the pin on the same area of the left hand.
d.Touch the pin on the same area of the left hand.
