Adult Health Final practice questions
Maintaining an aseptic environment in the OR is essential to client safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?
1 foot (30cm)
A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
2-3 soft bowel movements daily
A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which client as having the highest risk for chronic pancreatitis?
39 year old man with chronic alcoholism
The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning the client, wound dehiscence with evisceration occurs. What should be the nurse's first response?
Place saline soaked sterile dressings on the wound
The home care nurse is assessing the home environment of a client who will be discharged from the hospital shortly after a laryngitis. The nurse should encourage the client to use which appliance during recovery at home?
A room humidifier
A client's health care provider has ordered a "liver panel" in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply.
ALT, GGT, AST
The nurse is planning the care of a client with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this client's health problem is due to which issue with the red blood cells (RBCs)?
Abnormalities in the structure of function of RBCs
A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan?
Admin of diuretics as prescribed
The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client?
Airway patency
The nurse is planning teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching?
As soon as possible, before the surgical procedure
A client's low hemoglobin level has necessitated transfusion of packed red blood cells. Prior to administration, which action should the nurse perform?
Assess clients vital signs to establish baselines
The nurse is admitting a client who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this client's diagnosis of type 1 diabetes affect the care that the nurse plans?
Assess the blood glucose levels frequently
Post op, a client has a shallow RR and is reluctant to cough or begin mobilizing. The client is at increased risk for what complication
Atelectasis
The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk?
Atelectasis
A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores?
Beef liver with orange juice
A student nurse is caring for a client who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments?
Blood glucose levels
A client has been treated in the hospital for an episode of acute pancreatitis. The client has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for lifestyle changes. What is the nurse's most appropriate response?
Encourage the client to connect with a community based support group
In anticipation of a client's scheduled surgery, the nurse is teaching the client to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client?
Client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs
The nurse just received a postoperative client from the postanesthesia care unit to the medical-surgical unit. The client had surgery for a left hip replacement. Which concern should the nurse prioritize for this client in the first few hours on the unit?
Closely monitor neuro status
Two units of packed red blood cells have been prescribed for a client who has experienced a gastrointestinal bleed. The client is highly reluctant to receive a transfusion, stating, "I'm terrified of getting acquired immunodeficiency syndrome (AIDS) from a blood transfusion." How can the nurse best address the client's concerns?
Donated blood is screened for HIV and the risk of contraction is very low
The surgeon's preoperative assessment of a client finds that the client is at a high risk for venous thromboembolism. Once the client is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the client's risk of this complication?
Encourage early ambulation
A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments?
Daily weights and abdominal girth measurement
A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the condition. The nurse explains to this client that this condition occurs due to which factor?
Decreased production of platelets
The nurse explains how oxygen and carbon dioxide are exchanged between pulmonary capillaries and the alveoli. The nurse is describing what process
Diffusion
A client on the medical unit is receiving a unit of packed red blood cells (PRBCs). Difficult intravenous (IV) access has necessitated a slow infusion rate, and the nurse notes that the infusion began 4 hours ago. Which action by the nurse is the most appropriate?
Discontinue the remainder of the transfusion and inform the provider
A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action?
Discontinue the transfusion
The operating room nurse is participating in the appendectomy of a client who has a dangerously low body mass index. The nurse recognizes the client's consequent risk for hypothermia. Which action should the nurse implement to prevent the development of hypothermia?
Ensure that IV fluids are warmed to the clients body temp
A client will be undergoing a total hip arthroplasty later in the day and it is anticipated that the client may require blood transfusion during surgery. How can the nurse best ensure the client's safety if a blood transfusion is required?
Ensure the client has a current cross match
What nursing action will best reduce the clients risk for electrolyte disturbances
Ensure the client has sufficient potassium intake
An adult client has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status?
Fatigue related to decreased oxygen carrying capacity
A plan of care includes assessment of specific gravity every 4 hours. The result of this test will allow the nurse to assess which aspect of the clients health
Fluid volume status
A nurse at a blood donation clinic has completed the collection of blood from a client. The client reports feeling "light-headed" and appears pale. Which action by the nurse is most appropriate?
Help the client sit with head lowered below the knees
Client had a tonsillectomy. What assessment complication may come first after this surgery
Hemorrhage
A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation?
How many alcoholic drinks do you typically consume in a week
What causes a fluid imbalance
Hydrostatic pressure resulting form the pumping action of the heart
The client reports an onset of weakness with abdominal pain and likely has fluid volume deficit. The nurse thinks that the client might be experiencing which deficit
Hypercalcemia
The nurse is preparing an elderly client for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the client?
Hypothermia
A mother is asking for amoxicillin for viral rhinitis. What should the nurse explain to this mother
I will inform the doctor, but if it is a cold, antibiotics wont be used because they do not affect the virus
The nurse is preparing to change a client's abdominal dressing. The nurse recognizes that the first step is to provide the client with information regarding the procedure. Which explanation should the nurse provide to the client?
I will provide privacy. The dressing change should not be painful, you may look at the incision and help
A nurse in a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include which action?
Implementing plan of care for fall prevention
The intraoperative nurse knows that the client's emotional state can influence the outcome of the surgical procedure. How should the nurse best address this?
Incorporate cultural and religious considerations as appropriate
A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform which action?
Increase fluid intake
A client's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the client's laboratory studies, what finding is most closely associated with this diagnosis?
Increased bilirubin
Which of the following alterations would cause the release of ADH
Increased serum sodium
What principle should guide the nurses assessment of the clients skin turgor
Inelastic skin turgor is a normal part of aging
The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and body mass index increase the risk for what complication in the postoperative period?
Infection
Edema and coolness around IV site
Infiltration
A client has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the client's consequent increase in red cell production, the nurse should recommend the client increase daily intake of what substance?
Iron
A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?
It poses fewer risks than an open procedure
The anesthetist is coming to the surgical admissions unit to see a client prior to surgery scheduled for tomorrow morning. What is the priority information that the nurse should provide to the anesthetist during the visit?
Latex Allergy
A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery?
Leg exercises improve circulation and prevent venous thrombosis
The client stops drinking water early in the day because it is too difficult to get up in the night to go to the bathroom. The nurse should respond
Limiting your fluids can create imbalances that can result in confusion, so lets try adjusting the timing of your fluids
A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods?
Low fat foods high in protein and carbs
The nurse is caring for a client who has just been transferred to the PACU from the OR. What is the highest nursing priority?
Maintaining a patent airway
Dissolved particles in clients blood creating pressure for the fluids in the tissue to shift into the capillaries and increase the blood volume. This process is best described as
Osmosis and osmolality
The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of a spinal tumor in an effort to relieve pain. The nurse should plan this client care with the knowledge that this surgical procedure is classified as which of the following?
Palliative
What assessment finding would suggest that potassium level is too low
Paresthesias
The operating room nurse acts in the circulating role during a client's scheduled cesarean section. For which task is this nurse responsible?
Performing documentation
A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level?
Petechiae
A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do?
Place bed in a low position with side rails up
The circulating nurse will be participating in a 78-year-old client's total hip replacement. Which consideration should the nurse prioritize during the preparation of the client in the operating room?
Pressure points should be assessed and well padded
A client undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions?
Prevention of viral infections from another persons blood
The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication?
Pulmonary embolism
A client with liver disease has developed ascites; the nurse is collaborating with the client to develop a nutritional plan. The nurse should prioritize which of the following in the client's plan?
Reduction of sodium intake
The labs indicate a high serum creatine. The nurse should assess which body system for signs of injury
Renal
A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response?
Report finding to provider due to the possibility of haptic encephalopathy
A client who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this client knows to immediately report what assessment finding to the health care provider?
Rigidity of the abdomen
A client has been living with a diagnosis of anemia for several years and has experienced recent declines in hemoglobin levels despite active treatment. Which assessment finding would signal complications of anemia?
SOB and peripheral edema
A nurse is caring for a client who is undergoing preliminary testing for a hematologic disorder. Which sign or symptom of a hematologic disorder is most common?
Sever fatigue
A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process?
Severed blood vessels constrict
The nurse's review of a client's most recent blood work reveals a significant increase in the number of band cells. The nurse's subsequent assessment should focus on which of the following?
Signs and symptoms of infection
The dressing surrounding a client's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?
Trace the outline of the drainage on the dressing for future comparison
A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action?
Slow infusion rate and monitor the client closely
A critical care nurse is caring for a client with immune hemolytic anemia. The client is not responding to conservative treatments, and the client's condition is now becoming life-threatening. The nurse is aware that a treatment option in this case may include which intervention?
Splenectomy
The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take?
Stop the transfusion immediately
A client is admitted to the unit with acute cholecystitis. The health care provider has stated that surgery will be scheduled in 4 days. The client asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response?
Surgery is delayed until the acute symptoms subside
What should the preceptor tell the student about nursing care for clients with viral pharyngitis
Symptom management is the main focus of medical and nursing care
A client underwent an open bowel resection 2 days ago, and the nurse's most recent assessment of the client's abdominal incision reveals that it is dehiscing. Which factor should the nurse suspect may have caused the dehiscence?
The client has vomited three times in the past 12 hours
A client is being treated for the effects of a longstanding vitamin B12 deficiency. Which aspect of the client's health history would most likely predispose the client to this deficiency?
The client is a vegan
The nurse is taking the client into the operating room (OR) when the client informs the nurse that the client's grandparent spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client?
The client may be at risk for malignant hyperthermia
The nurse's brief review of a client's electronic health record indicates that the client regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible?
The client may chronically produce excess RBCs
A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse explain the pathophysiology of this client's health problem?
The enzymes that your pancreas produces have damaged the pancreas itself
The high communicability of the common cold is attributable to which factor
The virus is shed for 2 days prior to the emergence of symptoms
The postanesthesia care unit nurse is caring for a client who has arrived from the operating room. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the client is not breathing. Which intervention is the priority?
Tilt the head back and push forward on the angle of the lower jaw
A client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to vomit. What should the nurse do next?
Turn the client to one side
A client's coronary artery bypass graft has been successful, and discharge planning is underway. When planning the client's subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time?
When a follow up evaluation in the clinical or home setting is done
One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for a specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client?
You will need to have food and fluid restricted before surgery so you are not at risk for aspiration
A client with a hematologic disorder asks the nurse how the body forms blood cells. The nurse understands that this process takes place primarily in which location?
bone marrow
A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
fried chicken
A client presents to the emergency department (ED) reporting severe right upper quadrant pain. The client states that the family doctor said the pain was caused by gallstones. The ED nurse should recognize what possible complication of gallstones?
gangrene of the gallbladder
Reports tingling in lips and fingers and spasms in the wrist and hand and increased muscle tone. The nurse should first suspect
hypocalcemia
Symptoms of third spacing
hypovolemia
A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education?
iron will cause the stools to darken in color
The nurse's review of a client's most recent laboratory results indicates a bilirubin level of 3.0 mg/dL (51 mmol/L). The nurse assesses the client for:
jaundice
An adult client has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this client's plan of care?
measure the abdominal girth daily
A client is 2 hours' postoperative with an indwelling urinary catheter. The last hourly urine output recorded for this client was 10 mL. The tubing of the catheter is confirmed to be patent. What should the nurse do?
notify the health care provider and continue to monitor the hourly urine output
The nurse is providing care for a 73-year-old client who has a hematologic disorder. Which change in hematologic function is age-related?
older adults are less able to increase blood cell production when demand suddenly increases
A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region?
right shoulder
A client is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications?
vitamin B12
The nurse is providing client teaching to a young parent who has brought their 3-month-old infant to the clinic for a well-baby checkup. Which recommendation will the nurse make to the client to prevent the transmission of organisms to the infant during the cold season?
wash hands frequently
