Adult Health Exam 1
A patient is transferred from the post anesthesia care unit (PACU) to the surgical floor. Which would be the first action by the nurse on the clinical unit receiving the patient? a) Assess the patient's pain b) Take the patient's vital signs c) Orient the patient to the room d) Read the postoperative orders
b) Take the patient's vital signs
A nurse is reviewing nutrition teaching for a client who has cholecystitis. The nurse should identify that which of the following food choices can trigger cholecystitis? a) Baked potato b) Bowl of mixed fruit c) Brownie with nuts d) Grilled turkey
c) Brownie with nuts
A male client with cholecystitis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to find? a) Light, amber urine b) Black, tarry stools c) Circumoral cyanosis d) Yellow sclera
d) Yellow sclera
A 52 year old patient has a new diagnosis of pernicious anemia. After teaching the patient about pernicious anemia, the nurse determines that the patient understands the disorder when the patient states: a) "I will need cyanocobalamin replacement for the rest of my life." b) "I will need to start eating more red meat or liver." c) "I will need to take a proton pump inhibitor to decrease gastric secretions." d) "I will need to stop having a glass of red wine with dinner."
a) "I will need cyanocobalamin replacement for the rest of my life."
The client who had a cholecystectomy asks why a T-Tube has been inserted. The best response by the nurse is: a) "T-tubes drain edema fluid and bile to keep the duct patent." b) "T-tubes drain small gallstones." c) "T-tubes help us monitor for infection." d) "T tubes are always inserted following gallbladder surgery of any type."
a) "T-tubes drain edema fluid and bile to keep the duct patent."
A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following lab findings as indicators of the advanced disease process? Select all that apply a) ALT (alanine aminotransferase) elevated b) Prothrombin time (PT) shortened c) AST (aspartate aminotransferase) elevated d) Serum protein decreased e) Ammonia levels elevated
a) ALT (alanine aminotransferase) elevated c) AST (aspartate aminotransferase) elevated e) Ammonia levels elevated
Which topic is most important to include in patient teaching for a male client diagnosed with early cirrhosis? a) Avoiding alcohol ingestion b) Using vitamin B supplements c) Taking lactulose (Cephulac) d) Maintaining good nutrition
a) Avoiding alcohol ingestion
A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as possible contributors to this client's condition? Select all that apply. a) BMI (body mass index) of 46 b) Taking oral contraceptives c) Vegetarian diet d) Consuming 4 onuces of red wine daily e) Recent weight loss of 50 pounds in past 6 months f) Type II diabetes
a) BMI (body mass index) of 46 b) Taking oral contraceptives e) Recent weight loss of 50 pounds in past 6 months f) Type II diabetes
A nurse is caring for four clients with anemia. After hand-off report, which client should the nurse see first? a) Client who had two bloody diarrhea stools this morning b) Client with a respiratory rate change from 16 to 18 breaths/min c) Client with an unchanged lesion to the lower right lateral malleolus d) Client who has been premedicated for nausea prior to transfusion therapy
a) Client who had two bloody diarrhea stools this morning
Which menu choice indicates that the patient understands the nurses' teaching about best dietary choices for iron-deficiency anemia? a) Egg, kale and spinach omelet b) Strawberry and banana fruit plate c) Cornmeal muffin with orange juice d) Cantaloupe and cottage cheese
a) Egg, kale and spinach omelet
A nurse is obtaining informed consent for a client who is having a colonscopy through same day surgery. Which of the following are appropriate nursing actions. Select all that apply. a) Ensure client understands information about the procedure b) Explain to the client the purpose of having the procedure c) Determine if the client is capable of understanding the reason for the procedure d) Inform the client of the risks to having the procedure e) Witness the client signing the informed consent form
a) Ensure client understands information about the procedure c) Determine if the client is capable of understanding the reason for the procedure e) Witness the client signing the informed consent form
A patient's T-tube has drained 300 cc dark green fluid in the 24 hours following gallbladder surgery. All of the following are appropriate assessments and expectations from the nurse regarding a T-tube except? a) Expect removal of the T-tube within 48 hours. b) Document the color and amount of drainage c) Report absence of drainage with nausea to health care provider. d) Assessment of stools for color.
a) Expect removal of the T-tube within 48 hours.
All but which of the following would be an appropriate nursing diagnosis for a patient experiencing anemia: a) Impaired airway clearance b) Impaired gas exchange c) Fatigue d) Activity Intolerance
a) Impaired airway clearance
A nurse is planning care for a client who has a Hgb of 7.5 g/dL and Hct of 21.5%. Which of the following actions should the nurse include in the plan of care? Select all that apply. a) Monitor oxygen saturation b) Obtain stool specimen for occult blood c) Provide assistance with ambulation d) Schedule daily rest periods e) Weigh the client weekly
a) Monitor oxygen saturation b) Obtain stool specimen for occult blood c) Provide assistance with ambulation d) Schedule daily rest periods
Partial thromboplastin time (PTT) is increased with enoxaparin (Lovenox) therapy. a) True b) False
a) True
Pre-operative medications are given to inhibit gastric secretion and help prevent aspiration. a) True b) False
a) True
The lumen size of the indwelling Foley catheter most commonly used for adults is a 14 - 16 French. a) True b) False
a) True
A nurse is completing pre-operative teaching for a client who will undergo a laparoscopic cholecystectomy. Which of the following should be include in the teaching? a) "The T-tube will remain in place for 1 - 2 weeks." b) "You may have shoulder pain following surgery." c) "The scope will be passed through the rectum." d) "You should limit how often you walk for 3 - 4 weeks."
b) "You may have shoulder pain following surgery."
A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? a) Tell the client there is no need to be anxious b) Ask the client to describe current feelings c) Reassure the client this surgery is common d) Determine if the client wants a chaplain
b) Ask the client to describe current feelings
The surgical unit has just received a patient with a history of smoking from the post anesthesia care unit (PACU). Which action is most important initially? a) Obtain the patient's blood pressure and temperature b) Assess the patient's respiratory status c) Remind the patient about the harmful effects of smoking d) Auscultate for adventitious breath sounds
b) Assess the patient's respiratory status
A nurse assesses a client who has pancreatitis. Which clinical manifestation indicates that the condition is chronic rather than acute? a) Positive Cullen's sign b) Clay colored stools c) Left upper quadrant or mid-epigastric pain after eating d) Temperature of 37.8o C (100.1o F)
b) Clay colored stools
A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what next action by the nurse is most important? a) Reviewing the client's medical record for known allergies b) Double-checking the client and blood product identification c) Documenting the events in the client's medical record d) Placing the client on strict bedrest until the pain subsides
b) Double-checking the client and blood product identification
After the nurse completes the preoperative teaching, Grace states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurses' best response? a) Why don't you decide after you return from the post anesthesia care unit (PACU). b) Early movement and ambulation will help prevent complications following your surgery c) The doctor will probably order you to lie flat for 24 hours d) It is always a good idea to rest quietly after surgery
b) Early movement and ambulation will help prevent complications following your surgery
A client with cirrhosis is admitted to the hospital. Which of the following assessments made by the nurse would indicate the presence of portal hypertension? a) Confusion b) Elevated blood pressure c) Asterixis d) Vomiting blood
b) Elevated blood pressure
A nurse is completing an admission assessment of a client who has acute pancreatitis. Which of the following findings should the nurse expect? a) Pain in right upper quadrant radiating to right shoulder b) Epigastric pain radiating to the back c) Report of pain being worse when sitting upright d) Pain relieved with defecation
b) Epigastric pain radiating to the back
During insertion of a Foley catheter in a female, each side of the labia and the area around the meatus (urethral opening) should be cleansed before the labial folds are spread apart with sterile fingers. a) True b) False
b) False
Prior to insertion of a Foley catheter, a client tells the nurse that he develops a rash when wearing rubber gloves. The nurse determines she can continue with the Foley insertion, as the catheter will not come in contact with the patient's skin. a) True b) False
b) False
Serum hemoglobin levels can be affected by a patient's hydration (volume) status? a) True b) False
b) False
Which of the following is a primary nursing intervention necessary for all patients with a Foley catheter in place? a) Irrigate the patient's bladder with a 1% Neosporin solution three times daily b) Maintain the drainage tubing and collection bag below bladder level c) Maintain the drainage tubing and collection bag level with the patient's bladder d) Clamp the catheter for 1 hour every 4 hours to maintain the bladder's elasticity
b) Maintain the drainage tubing and collection bag below bladder level
The clinic nurse reviews the complete blood count (CBC) results for a male client who is scheduled for surgery in one day. The results are RBC 4,800 (4.8 m/uL); WBC 7,200 (7.2 k/uL); Hbg 15 g/dL; Hct 45%. Which action should the nurse take? a) Ask the patient about any symptoms of a recent infection b) No action is needed. These are normal results. c) Call the surgeon and anesthetist immediately d) Discuss the possibility of a blood transfusion with the patient
b) No action is needed. These are normal results.
The nurse assesses a patient with Vitamin B12 deficiency (pernicious anemia). Which assessment finding would the nurse expect? a) Yellow tinged sclera b) Numbness and tingling of the extremities c) Gum bleeding and tenderness d) Cracks by the lips
b) Numbness and tingling of the extremities
A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take when admitting the patient pre-operatively? a) Give the patient the usual insulin dose because stress will increase the blood glucose level b) Obtain a blood glucose measurement before any insulin is administered c) Give the patient the usual scheduled insulin dose because the patient is NPO d) Administer a lower dose of insulin because there will be no oral intake before surgery
b) Obtain a blood glucose measurement before any insulin is administered
All but which of the following are reasons a physician might order insertion of an urinary catheter? a) Obtaining a sterile urine specimen b) Preventing urinary incontinence c) Relieving urinary retention d) Emptying the bladder during surgery
b) Preventing urinary incontinence
Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change? a) Using sterile forceps, rather than sterile gloves, to handle a sterile item b) Reaching across the open sterile field c) Placing a sterile object more than 1 inch inside the edge of the sterile field d) Touching equipment within a sterile field with sterile gloves
b) Reaching across the open sterile field
A client with vitamin B12 deficiency anemia has been taught to eat foods high in Vitamin B12. Which meal selected by the client indicates that he or she understands the prescribed diet? a) Eggplant parmesan, cream-style cottage cheese and iced tea b) Salmon, spinach salad and milk c) Baked chicken breast, boiled carrots, and orange juice d) Green leaf salad with vegetable oil dressing, strawberries and milk
b) Salmon, spinach salad and milk
A 59 year old man is scheduled for a herniorrhaphy tomorrow. During the preoperative evaluation he reports that he has been taking the supplement ginkgo biloba daily. What is the priority intervention? a) Ask the patient if he has noticed any side effects from taking this herbal supplement b) Tell the patient to discontinue taking the herbal supplement immediately c) Tell the patient to continue to take the herbal supplement up to the day before surgery
b) Tell the patient to discontinue taking the herbal supplement immediately
A patient is hospitalized for treatment of severe anemia. An appropriate nursing action for the patient is to: a) provide a diet high in vitamin K b) alternate periods of rest and activity c) teach the patient how to avoid injury d) place the patient in protective isolation
b) alternate periods of rest and activity
The nurse is providing discharge teaching for a client who will be receiving pancreatic enzyme replacement at home. Which statement by the client is incorrect? a) "I should wipe my lips with a wet towel carefully after taking the enzymes." b) "I should take my pancreatic enzyme with meals." c) "I should take my pancreatic enzyme after meals and snacks." d) "I should not chew or crush tablets or capsules."
c) "I should take my pancreatic enzyme after meals and snacks."
After the nurse has finished teaching a patient about oral ferrous sulfate (Feosol), which statement indicates that additional instruction is needed? a) "I should increase my fluid and fiber intake while I am taking the iron tablets." b) "I will drink the liquid form through a straw." c) "I will call the doctor if my stools turn dark." d) "I should take the iron with orange juice about an hour before eating."
c) "I will call the doctor if my stools turn dark."
The patient puts on their call light and states they are able to see "internal organs" at their incision site. What is the patient describing? a) Poor wound healing b) A dehiscence c) An evisceration d) An infection
c) An evisceration
Postoperatively, the nurse assesses an area of drainage on the dressing of a patient's surgical wound and note's a quarter size area of pink drainage underneath the dressing. Which of the following should the nurse do? a) Call the surgeon right away about the drainage b) Pass the information off to the next shift c) Cover the current dressing with a new, clean dressing d) Outline the area and mark it with a date and time
c) Cover the current dressing with a new, clean dressing
A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a) Tell the client a little pain is expected b) Instruct the client to take shallow breaths. c) Demonstrate how to splint the abdomen incision d) Call the provider to request more analgesia
c) Demonstrate how to splint the abdomen incision
When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse would review which component of the complete blood count (CBC) for a possible cause? a) Platelet count b) Neutrophil count c) Hemoglobin level d) Hematocrit level
c) Hemoglobin level
A nurse is preparing to administer an intramuscular (IM) dose of iron to a client with anemia. Which of the following precautions should the nurse take? Select all that Apply a) Administer the drug utilizing a Z-track technique b) Use a 1-inch, 19 gauge needle c) Massage the area vigorously after administering the iron d) Administer the drug deep in the deltoid muscle
c) Massage the area vigorously after administering the iron d) Administer the drug deep in the deltoid muscle
The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." What action is best for the nurse to take? a) Provide an explanation of the planned surgery to the patient b) Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications c) Notify the surgeon that the patient needs more information on the planned surgery d) Notify the operating room staff of the patient's concerns
c) Notify the surgeon that the patient needs more information on the planned surgery
A client who had a surgical repair of a hip fracture 2 days previously, has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for this patient is? a) Potential complication: infection b) Potential complication: impaired surgical wound healing c) Potential complication: venous thromembolism d) Potential complication: fluid and electrolyte imbalance
c) Potential complication: venous thromembolism
A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important? a) Removing the dressing and assessing the surgical site b) Preparing to administer a blood transfusion c) Taking a set of vital signs and notifying the surgeon d) Reinforcing the dressing and documenting findings
c) Taking a set of vital signs and notifying the surgeon
The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should: a) Tell the client that she can expect lower abdominal pain for the next week b) Tell the client that she can resume a regular diet in the next 24 hours c) Tell the client they can resume their normal activities in 1 - 3 weeks. d) Teach the client how to remove the T-tube
c) Tell the client they can resume their normal activities in 1 - 3 weeks.
For the nursing diagnosis of Ineffective Airway Clearance in a postoperative patient, the nurse evaluates that the interventions have been successful when: a) the patient uses the incentive spirometer 10 times every hour b) the patient drinks 2 - 3 liters of fluid in 24 hours c) the patient's breath sounds are clear to auscultation d) the patient's temperature is less than 100.4o F orally
c) the patient's breath sounds are clear to auscultation
Which intervention by the nurse will be the most helpful in promoting ambulation, coughing, deep breathing, and turning by a patient on the first postoperative day? a) Give the patient positive reinforcement for accomplishing these activities b) Discuss the complications of immobility and poor cough effort c) Teach the patient the purpose of respiratory care and ambulation d) Administer ordered analgesic medications before these activities
d) Administer ordered analgesic medications before these activities
A female client is admitted to the hospital with a hemoglobin of 10 g/dL. When assessing this client, the nurse should expect which symptom? a) Skin flushed and warm b) Shortness of breath with exertion c) Heart rate of 45 beats/minute d) Blood pressure of 150/85 mmHg
d) Blood pressure of 150/85 mmHg
An unconscious patient is admitted to the ICU. An order for a Foley catheter is received. The nurse knows that with a foley catheter inserted, urinary infection is a potential danger. The nurse can best plan to avoid this problem by? a) Emptying the drainage bag every 4 hours b) Assessing urine specific gravity c) Collecting a weekly urine specimen d) Maintaining a sterile technique during insertion
d) Maintaining a sterile technique during insertion
The nurse is inserting a foley catheter. After holding the penis in their gloved hand to cleanse the meatus, The nurse takes the hand away to pick up the catheter tray and move it to the patient's legs. What is the next best action the nurse should take? a) Pick up catheter to remove from tray. b) Lubricate the end of the catheter tubing. c) Prepare the client for insertion by instructing them to "take a deep breath." d) Remove gloves and obtain new sterile gloves to complete procedure.
d) Remove gloves and obtain new sterile gloves to complete procedure.
Which of the following laboratory test results will the nurse monitor when evaluating if treatment is effective for a 62 year old who has acute pancreatitis? a) Urine Bilirubin b) AST (Asparate aminotransferase) c) Serum Potassium d) Serum Amylase
d) Serum Amylase
The nurse is conducting nutrition counseling for a patient post cholecystectomy. Which of the following information is important to communicate? a) The patient should maintain a low calorie diet 1200 calories/day or less. b) The patient must maintain a high protein/low carbohydrate diet. c) The patient must be sure to have three large meals each day. d) The patient should limit fatty, gas forming foods.
d) The patient should limit fatty, gas forming foods.
The first 24 hours after surgery, when caring for a patient following an incisional (open) cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to: a) Choose low fat foods from a menu b) Perform leg exercises hourly while awake c) Ambulate the day after surgery d) Turn, cough, and deep breathe every 2 hours
d) Turn, cough, and deep breathe every 2 hours
