Adult health Exam 1

A patient who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurse's priority action? a. Have the patient lie down. b. Assess the patient's airway. c. Administer high-flow oxygen. d. Remove the stinger from the site.

b. Assess the patient's airway.

A nurse is teaching a group of clients about first aid care for a bee sting. Which of the following information should the nurse include in the teaching? A. Remove the stinger by scraping it off with a knife blade. B. Apply a tourniquet. C. Apply a warm pack. D. Suck the wound

A. Remove the stinger by scraping it off with a knife blade.

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? A. I should wash my hands after blowing my nose to prevent spreading the virus B. I need to avoid drinking fluids if i develop symptoms C. I need a flu shot every 2 years because of the different flu strains D. I should cover my mouth with my hand when I sneeze

A. I should wash my hands after blowing my nose to prevent spreading the virus

Which factor puts an older adult at the greatest risk for impaired wound healing after abdominal surgery? a. age over 75 years b. poorly conducted diabetes c. history of one myocardial infarction d. chronic peripheral vascular disease

a. age over 75 years

The nurse is preparing to set up an intravenous infusion of normal saline 1,000 mL over a 6 hour period. The tubing drop factor is 10 gtt/mL. Which of the following rates of infusion should the nurse choose? A. 12 gtt/min B. 28 gtt/min C. 33 gtt/min D. 36 gtt/min

B. 28 gtt/min

A nurse is assessing a client who is taking oxacillin to treat an infection. The nurse should recognize which of the following findings is a manifestation of an allergic reaction? A. Diarrhea B. Pruritus C. Dark urine D. Fever

B. Pruritus

A nurse is caring for a male client who has a new diagnosis of genital herpes (HSV2). Which of the following findings should the nurse expect? A. anuria B. influenza-like symptoms C. white- or flesh-colored papillary growth in genital area D. green penile discharge

B. influenza-like symptoms

A group of nurses are discussing risk factors for transmission of human immunodeficiency virus (HIV) from clients. Which of the following individuals should the nurse identify as being at the greatest risk for contracting HIV? A) An occupational therapist who works with a client who has HIV B) A personal trainer who works with a client who has HIV C) A phlebotomist who collects blood from clients who have HIV D) A nurse who works for an insurance company and collects urine samples from clients who have HIV

C) A phlebotomist who collects blood from clients who have HIV

The nurse is preparing to assess a client when one of the client's family members begins showing symptoms of a mild latex sensitivity. Which action by the nurse is best? A) Ask the family member to leave the unit. B) Transfer the client to a department that does not use latex products. C) Wait until Monday to report the problem to the supervisor of the unit. D) Obtain latex-free products for the client's room.

D) Obtain latex-free products for the client's room.

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? A) Positive western blot test B) CD4-T-cell count 180 cells/mm C) Platelets 150,000/mm D) WBC 5,000/mm

D) WBC 5,000/mm

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? A. BUN B. Potassium C. RBC count D. WBC count

D. WBC count

The nurse is assessing a group of older adults. which client is at greatest risk for skin breakdown? a. altered balance b. reduced sensation of pressure c. impaired hearing ability d. impaired visual acuity

b. reduced sensation of pressure

A nurse is preparing to administer heparin 2,000 units by IV bolus. Available is heparin injection 5,000 units/mL. How many mL should the nurse administer? a. 0.4 mL b. 1 mL c. 0.2 mL d. 4 mL

a. 0.4 mL

A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first? a. Administer epinephrine. b. Ask the patient about exposure to any new lotions or soaps. c. Apply topical hydrocortisone. d. Monitor the patient for lower extremity edema

a. Administer epinephrine.

A client with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. Which outcome would the nurse recognize as most appropriate for this patient? a. Client has a balanced intake and output. b. Client's bedding is changed when it becomes damp. c. Client understands the need for increased fluid intake. d. Client's skin remains cool and dry throughout hospitalization.

a. Client has a balanced intake and output.

A nurse is assessing a client who is postoperative and finds the client's abdominal incision has eviscerated. Which of the following actions should the nurse take? a. Cover the wound with a sterile saline-soaked dressing b. Place the client in high-fowler's position c. Auscultate all quadrants of the abdomen for bowel sounds d. Gently reinsert the protruding tissue

a. Cover the wound with a sterile saline-soaked dressing

A nurse wants to reduce the risk potential for transmission of chlamydia and gonorrhea with a female client diagnosed with both diseases. Which items should be included in the clients teaching plan? (Select all that apply.) a. Expedited partner therapy b. Abstinence until therapy is completed c. Use of internal uterine devices d. Proper use of condoms e. Re-screening for infection

a. Expedited partner therapy b. Abstinence until therapy is completed d. Proper use of condoms e. Re-screening for infection

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish,". Which of the following is the priority nursing action? a. Notify the provider of the client's allergy b. Attach a wrist band indicating the clients allergy c. Ask the client if any other foods cause such a reaction d. Notify the dietary department of the client's allergy

a. Notify the provider of the client's allergy

A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first? a. Obtain cultures of the wound. b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings.

a. Obtain cultures of the wound.

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? a. Poor nutritional status b. obesity c. pain medication administration d. wound infection e. altered mental status

a. Poor nutritional status b. obesity d. wound infection

When completing an admission assessment on an older client, the nurse gives the client a high fall risk score. Which action should the nurse take first? a. Use a bed alarm system on the patient's bed. b. Administer the prescribed PRN sedative medication c. Ask the health care provider to order a vest restraint d. Place the patient in a "geri-chair" near the nurse's station

a. Use a bed alarm system on the patient's bed.

The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would best encourage medication compliance? a. Use a marked pillbox to set up the client's medications b. Discuss the option of moving to an assisted living facility c. Remind the client about the importance of taking medications d. Visit the client daily to administer the prescribed medications

a. Use a marked pillbox to set up the client's medications

The nurse is instructing an older adult about ways to promote skin integrity. Which health maintenance behavior by the client is most helpful? a. drinks 1,500 mL of fluids per day b. consumes a balanced diet of 1,200 cal/day c. walks briskly for 10 minutes three times per week d. sleeps at least 8 hours each night.

a. drinks 1,500 mL of fluids per day

A older adult has pruritus on the arms and legs and is scratching the affected arears. Which is the priority nursing care for this client? a. prevention infection b. instructing the client not to scratch c. increasing fluid intake d. avoiding isolation

a. prevention infection

The nurse is assessing a client with a pressure ulcer. Which indicates that a client has a stage 2 pressure ulcer? a. redness in the involved area b. pain in the involved area c. muscle spasms in the involved area d. tissue necrosis in the involved area

a. redness in the involved area

A client has a wound on the ankle that is not healing. The nurse should assess the client for which risk factors for delayed wound healing? (Select all that apply.) a) atrial fibrillation b) type 2 diabetes mellitus c) smoking d) advancing age e) hypertension

b) type 2 diabetes mellitus d) advancing age c) smoking

A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take? a. Notify the dietitian about the food allergies. b. Alert the surgery center about a possible latex allergy. c. Reassure the patient that all allergies are noted on the medical record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.

b. Alert the surgery center about a possible latex allergy.

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.

b. Document the assessment.

A nurse is calling the on-call physician about a patient who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for communication? a. "I would like you to order a different pain medication" b. This patient has allergies to morphine and codeine" c. "Dr. Smith doesn't like nonsteroidial anti-inflammatory meds" d. "This patient had a vaginal hysterectomy 2 days ago

b. This patient has allergies to morphine and codeine"

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record? a. stage 1 pressure ulcer b. stage 2 pressure ulcer c. stage 3 pressure ulcer d. stage 4 pressure ulcer

b. stage 2 pressure ulcer

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. I need to find another way to earn extra money b. "I will get a prescription for epinephrine and learn to self-inject it." c. "I will plan to take oral antihistamines before going to work." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."

c. "I will plan to take oral antihistamines before going to work."

A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate? a. Measurement of a patient's urine output by UAP b. Administration of oral medications by LPN/LVN c. Check for the presence of bowel sounds and flatulence by UAP d. Care of a patient with diabetes by RN who usually works on the pediatric unit

c. Check for the presence of bowel sounds and flatulence by UAP

While obtaining a health history from a patient, the nurse learns that the patient has a history of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate? a. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. b. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves. c. Document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy. d. Recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen contact.

c. Document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy.

A nurse is assessing a client who presents with a scaly rash over the palms and soles of the feet and the feeling of muscle aches and malaise. The nurse suspects syphilis. Which action by the nurse is most appropriate? a. Reassure the client that this stage is not infectious unless she is pregnant b. Assess the client for healing loss and generalized weakness c. Don gloves and further assess the client's lesions d. Take a history regarding any cardiovascular symptoms

c. Don gloves and further assess the client's lesions

An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first? a. Notify an elder protective services agency about the possible abuse b. Make a referral for a home assessment visit by the home health nurse c. Have the family member stay in the waiting area while the client is assessed d. Ask the client how the injury occurred and observe the family member's reaction

c. Have the family member stay in the waiting area while the client is assessed

A client who is paralyzed on the left side of the body after a stroke develops a pressure a pressure ulcer on the left hip. Which nursing diagnosis is most appropriate? a. Impaired physical mobility related to left-sided paralysis b. Risk for impaired tissue integrity related to left-sided weakness c. Impaired skin integrity related to altered circulation and pressure d. Ineffective tissue perfusion related to inability to move independently

c. Impaired skin integrity related to altered circulation and pressure

The nurse is assessing a client with dark skin for the presence of a stage I pressure ulcer. Which is the best approach to making this assessment? a. Use a fluorescent light source to assess the skin b. Inspect the skin only when the Braden score is above 12 c. Look for skin color that is darker that the surrounding tissue d. Avoid touching the skin during inspection

c. Look for skin color that is darker that the surrounding tissue

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure

c. Rising body temperature

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

c. Stage III

An older adult is having abdominal surgery. The nurse should assess the client for which postoperative concern related to normal changes in the integumentary system of an older adult? a. increased scarring b. decreased melanin and melanocytes c. decreased healing d.increased immunocompetence

c. decreased healing

The nurse is assessing a client who is immobile and notes an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next? a.Apply a moist to moist dressing, being careful to pack just the wound bed b.Consult with a wound ostomy continence nurse specialist. c.Reposition the client off of the reddened skin and reassess in a few hours. d.Complete and document a Braden skin breakdown risk score for the client

c.Reposition the client off of the reddened skin and reassess in a few hours.

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method.

d. Administer skin testing by the cutaneous scratch method.

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? a. Soak the old dressings with sterile saline 30 minutes before removing them. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.

d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.

Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective? a. Heart rate b. Orientation c. Blood pressure d. Oxygen saturation

d. Oxygen saturation

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose 136 mg/dL b. Oral temperature 101° F (38.3° C) c. Patient complaint of increased incisional pain d. Separation of the proximal wound edges by 1 cm

d. Separation of the proximal wound edges by 1 cm

A 19-year-old female is asking the nurse about the vaccine for human papilloma virus (HPV). Which statement by the nurse is accurate? a. Gardasil protects against all HPV strains. b. You are too young to receive the vaccine. c. Only females can receive the vaccine. d. This will lower your risk for cervical cancer.

d. This will lower your risk for cervical cancer.

While evaluating a male client for treatment of gonorrhea, which question is the most important for the nurse to ask? a. Do you have a history of sexually transmitted disease? b. When was your last sexual encounter? c. When did your symptoms begin? d. What are the names of your recent sexual partners?

d. What are the names of your recent sexual partners?

A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the evaluation phase of the nursing process? a.) To establish if the patient agrees that the nursing care provided was satisfactory b.) To document the nursing care plan in the progress notes of the medical record c.) To decide whether the patient's health problems have been completely resolved d.) To determine if interventions have been effective in meeting patient outcome

d.) To determine if interventions have been effective in meeting patient outcome