Adult Health and Illness 1 Final Exam Study Questions

A nurse is caring for a patient who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?

Validate that informed consent has been given by the patient

A client at risk for developing hyperkalemia states, "I love fruit and usually eat it every day, but now I can't because of my high potassium level." How should the nurse respond?

"Berries, cherries, apples, and peaches are low in potassium."

An emergency room nurse obtains the health history of a patient. Which statement by the patient should alert the nurse to the occurrence of heart failure?

"I get SOB when I climb the stairs."

A client is typed and crossmatched for a unit of blood. Which statement by the nurse indicates a need for further genetic education?

"If the client's blood type is AB, then the client is homozygous for that trait."

A student nurse asks what "essential hypertension" is. What response by the registered nurse is best?

"It is hypertension with no specific cause."

A nurse cares for a client who has a genetic mutation that increases the risk for colon cancer. The client states that he does not want any family to know about this result. How should the nurse respond?

"It is not required that you tell anyone about this result. However, your siblings and children may also be at risk for colon cancer and this information might help them."

A student nurse asks why brushing patients' teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?

"It mechanically removes biofilm on teeth"

A patient is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best?

"It prevents the start of cell division in the cancer cells."

A nurse is caring for a client who is terminally ill. The client's spouse states, "I am concerned because he does not want to eat." How should the nurse respond?

"Let him know that food is available if he wants it, but do not insist that he eat."

A nurse obtains the health history of a patient who is newly admitted to the medical unit. Which statement by the patient should alert the nurse to the presence of edema?

"My shoes fit tighter by the end of the day."

A medical-surgical nurse asks the nurse researcher, "What is the difference between qualitative and quantitative questions?" How should the nurse researcher respond?

"Quantitative questions identify relationships between measurable concepts."

A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this client's teaching?

"Read food labels to determine sodium content"

A nurse cares for a patient who has advanced cardiac disease and states, "I am having trouble sleeping at night." How should the nurse respond?

"Use pillows to elevate your head and chest while you are sleeping."

A nurse assesses a patient who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first?

"What medications are you taking?"

The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for completing a comprehensive pain assessment?

"What pain rating would be acceptable to you?"

A nurse is planning care for a client who is hyperventilating. The client's arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3- 26 mEq/L. Which question should the nurse ask when developing this client's plan of care?

"You appear anxious. What is causing your distress?"

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 should the nurse include in this patient's teaching?

"You should balance weight loss with consuming necessary nutrients."

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3- 19 mEq/L. Which assessment should the nurse perform first?

Cardiac rate and rhythm

A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet). What discharge instruction is most important for this client?

Check any OTC medications for acetaminophen

A hospice nurse is caring for a dying client and her family members. Which interventions should the nurse implement? (Select all that apply.)

- Teach family members about physical signs of impending death -Encourage the management of adverse symptoms -Encourage reminiscence by both client and family members

A nurse on the postoperative unit administers many opioid analgesics. What actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.)

-Avoid using other medications that cause sedation. -Give the lowest dose that produces good control. -Identify clients at high risk for unwanted sedation. -Use an oximeter to monitor clients receiving analgesia.

A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

-Keep the client's skin dry -Obtain a pressure-relieving mattress -Turn the client every 2 hours

A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies should the nurse incorporate in this client's pain management plan? (Select all that apply.)

-Play music that the client enjoys -Rub lavender lotion on the client's feet

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.)

-increased pulse rate -distended neck veins -skeletal muscle weakness

A nursing student caring for a patient removes the patient's oxygen as prescribed. The patient is now breathing what percentage of oxygen in the room air?

21 %

A health care facility is implementing a new evidence-based nursing protocol. Which action is necessary to ensure successful implementation?

Attain support from nurses who are implementing the protocol

A patient is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority?

Blood pressure

A rehabilitation nurse prepares to move a client who has new bilateral leg amputations. Which is the best approach?

Utilize the facility's mechanical lift to move the client

A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?

Call the Rapid Response Team

A nurse is assessing a patient who is recovering from a lung biopsy. Which assessment finding requires immediate action?

Absent breath sounds

A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right upper extremity PICC is intact, patent, and has a good blood return. Site clean and free from manifestations of infiltration, irritation, and infection. -Sue Franks, RN January 20: Purulent drainage from sacral wound. Wound cleansed and dressing changed. Dr. Smith notified and updated on client status. New orders received for intravenous antibiotics. -Sue Franks, RN January 13: Client alert and oriented. Sacral wound dressing changed. -Sue Franks, RN January 6: Right upper extremity PICC inserted. No complications. Discharged with home health care. -Dr. Smith Based on the information provided, which action should the nurse take?

Administer the prescribed medication

A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?

Anxious client who has tachypnea

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?

Apply oxygen by mask or nasal cannula

A group of nursing students has entered a futuristic science contest in which they have "developed" a cure for cancer. Which treatment would most likely be the winning entry?

Artificial fibronectin infusion to maintain tight adhesion of cells

A patient who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?

Assess medications records for steroid use///Chronic steroid use is seen in patients with SLE and can lead to osteonecrosis (bone necrosis).

A postoperative nurse is caring for a patient whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate?

Assess other indicators of oxygenation

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. Which action should the nurse take?

Assess the color and temperature of the left leg

A patient has been admitted to the hospital for a virulent infection and is started on antibiotics. The patient has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is best?

Assess the patient frequently for worsening of his or her condition

A nurse is caring for an older adult patient who has a pulmonary infection. Which action should the nurse take first?

Assess the patient's level of consciousness

A patient has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the patient's face is puffy and the eyelids are swollen. What action by the nurse takes priority?

Assess the patient's oxygen saturation

A nurse is caring for a patient who has a pressure ulcer on the right ankle. Which action should the nurse take first?

Assess the right leg for pulses, skin color, and temperature

A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first?

Client with a respiratory rate of 8 breaths/min

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia?

Client with pancreatitis who has continuous nasogastric suctioning

A health care provider prescribes genetic testing for a client who has a family history of colorectal cancer. Which action should the nurse take before scheduling the client for the procedure?

Confirm that informed consent was obtained and placed on the client's chart

A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?

Connect the client to a cardiac monitor

The nurse working with oncology patients understands that which age-related change increases the older patient's susceptibility to infection during chemotherapy?

Decreased immune function

A patient is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?

Determine if the patient can switch to a nasal cannula during the meal

A nurse auscultates a harsh hollow sound over a patient's trachea and larynx. Which action should the nurse take first?

Document the findings

A student nurse asks the faculty to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty is most accurate?

Don't make assumptions about their health needs

A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?

Ensure an x-ray is completed to confirm placement.

A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse?

Ensuring patient safety

A patient hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer?

Epoetin alfa (Epogen)

A nurse cares for patients who have various skin infections. Which infection is paired with the correct pharmacologic treatment?

Fungal infection - Ketoconazole (Nizoral)

The nurse is caring for four hypertensive patients. Which drug-laboratory value combination should the nurse report immediately to the health care provider?

Furosemide (Lasix)/potassium: 2.1 mEq/L

A patient is started on etanercept (Enbrel). What teaching by the nurse is most appropriate?

Giving subcutaneous injections

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates the client correctly understood the teaching?

Grilled chicken breast with glazed carrots

The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells?

Growing in the wrong place or time is typical of benign tumors

A patient is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important?

Have adequate help to transfer the patient

A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety?

Have another nurse double-check the pump settings

A nurse assesses a patient and identifies that the patient has pallor conjunctivae. Which focused assessment should the nurse complete next?

Hemoglobin and hematocrit

After teaching a patient who is at risk for the formation of pressure ulcers, a nurse assesses the patient's understanding. Which dietary choice by the patient indicates a good understanding of the teaching?

High-protein diet with vitamins and mineral supplements

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3- 18 mEq/L. Which manifestation should the nurse identify as an example of the client's compensation mechanism?

Increased rate and depth of respirations

A nurse cares for a patient who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this patient waits for surgery?

Initiation of an external pacemaker

A nurse performs a skin screening for a patient who has numerous skin lesions. Which lesion does the nurse evaluate first?

Irregular blue mole with white specks on the lower leg

A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion?

Judaism - A person who is extremely ill and dying should not be left alone.

An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client?

Keep the light on in the bathroom at night

During skin inspection of a patient, a nurse observes lesions with wavy borders that are widespread across the patient's chest. Which descriptors should the nurse use to document these observations?

Linear and circinate

A nurse is caring for four patients. Which one should the nurse see first?

patient who had a first dose of captopril (Capoten) and needs to use the bathroom

A nurse obtains the health history of a patient who is recently diagnosed with lung cancer and identifies that the patient has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this patient?

Maintain a nonjudgmental attitude to avoid causing the patient to feel guilty

A nurse is caring for a client who has lung cancer and is dying. Which prescription should the nurse question?

Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5

A nurse is assessing a patient with glioblastoma. What assessment is most important?

Neurologic examination

A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal cannula. The following clinical data are available: Arterial Blood Gases Vital Signs pH = 7.28 Pulse rate = 96 beats/min PaO2 = 85 mm Hg Blood pressure = 135/45 PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min HCO3- = 26 mEq/L O2 saturation = 88% Which action should the nurse take first?

Notify the Rapid Response Team and provide ventilation support

A nurse receives report from the laboratory on a patient who was admitted for fever. The laboratory technician states that the patient has "a shift to the left" on the white blood cell count. What action by the nurse is most important?

Notify the provider and request antibiotics

A nurse is caring for a patient who received benzocaine spray prior to a recent bronchoscopy. The patient presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?

Notify the rapid response team

A nurse cares for a dying client. Which manifestation of dying should the nurse treat first?

Pain

While assessing a patient's lower extremities, a nurse notices that one leg is pale and cooler to the touch. Which assessment should the nurse perform next?

Palpate the patient's pedal pulses bilaterally

A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first?

Perform an oral assessment

A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this client's risk of fracture?

Perform weight-bearing activities

A nurse assesses an older patient who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take?

Place the patient in a single room

A patient is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first?

Place the patient on Airborne Precautions"

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?

Place warm compresses to the site

A preoperative nurse is reviewing morning laboratory values on four patients waiting for surgery. Which result warrants immediate communication with the surgical team?

Potassium 2.9

An older patient is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate?

Prepare to administer epoetin alfa (Epogen)

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

Prepare to assist with chest tube insertion.

A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?

Presence of an ulnar pulse

The student nurse learns that the most important function of inflammation and immunity is which purpose?

Providing protection against invading organisms

A nurse assesses a patient after administering a prescribed beta blocker. Which assessment should the nurse expect to find?

Pulse decreased from 100 beats/min to 80 beats/min

A nurse assesses a patient who has open lesions. Which action should the nurse take first?

Put on gloves

A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety?

Remove the old patch when applying the new patch

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

Report of headache and stiff neck.

An older client who lives alone is being discharged on opioid analgesics. What action by the nurse is most important?

Request a home safety assessment

A nurse wants to explore why clients who receive patient-controlled analgesia (PCA) after abdominal surgery ambulate sooner than clients who receive nurse-administered pain medications. Which action should the nurse take first?

Search the medical library for the best evidence

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?

Teach the client fall prevention measures

Which statement about carcinogenesis is accurate?

Tumor cells need to develop their own blood supply

While assessing a patient, a nurse detects a bluish tinge to the patient's palms, soles, and mucous membranes. Which action should the nurse take next?

Use pulse oximetry to assess the patient's oxygen saturation

A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction?

Use the Credé maneuver every 3 hours.

A student asks the nurse what is the best way to assess a client's pain. Which response by the nurse is best?

clients self-report

A nurse assesses a patient after an open lung biopsy. Which assessment finding is matched with the correct intervention?

patient has reduced breath sounds - Nurse call physician immediately

An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying "Those are for old people." What action by the nurse would be most helpful?

put color-codes stickers on the bottle caps

A nurse is assessing pain in an older adult. What action by the nurse is best?

sit down, ask one question at a time, and allow the client to answer