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Adult Health Exam 3 ACCURATE TESTED
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A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What assessment finding by the nurse indicates that an important outcome for this client has been met? A) Client has no abdominal pain B) Client’s urine output is adequate C) Client is able to decrease blood pressure medications D) Client’s weight remains stable Correct Answer: C) Client is able to decrease blood pressure medications Rationale: Successful angioplasty restores blood flow to the kidney, lowering blood pressure and often reducing the need for antihypertensive medications. A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse is most important? A) Administer prescribed analgesics B) Elevate the affected leg C) Assess distal pulses and skin color D) Apply a warm compress Correct Answer: C) Assess distal pulses and skin color Rationale: Severe pain may indicate compromised perfusion; assessing circulation ensures graft patency before treating pain. A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? A) Change dressings daily B) Appropriate hand hygiene before giving care C) Administer prophylactic antibiotics D) Keep the leg elevated
Correct Answer: B) Appropriate hand hygiene before giving care Rationale: Hand hygiene is the most effective nursing intervention to prevent infection in a surgical site. A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse is most important? A) Stop the infusion B) Notify the Rapid Response Team C) Assess blood glucose D) Reorient the client Correct Answer: B) Notify the Rapid Response Team Rationale: Neurologic changes may indicate intracranial hemorrhage, a life-threatening complication of alteplase requiring immediate intervention. A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse requires the mentor to intervene? A) Monitors blood pressure closely B) Teaches the client to avoid straining C) Palpates the abdomen in four quadrants D) Assesses peripheral pulses Correct Answer: C) Palpates the abdomen in four quadrants Rationale: Palpation of the aneurysm can increase the risk of rupture; this action is unsafe. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met? A) Client’s calf is no longer tender B) Leg swelling is reduced C) Oxygen saturation of 98% D) Client reports less pain Correct Answer: C) Oxygen saturation of 98% Rationale: Maintaining oxygenation indicates no pulmonary embolism has developed, the most serious complication of DVT.
D) Notify the provider of client refusal Correct Answer: C) Assess the reason behind the client’s fear Rationale: Exploring the client’s concerns first allows individualized teaching and promotes adherence to therapy. A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril and warfarin. The client reports new onset cough. What action by the nurse is most appropriate? A) Hold the next dose of warfarin B) Assess the client’s lung sounds and oxygenation C) Increase the client’s fluid intake D) Notify the provider immediately Correct Answer: B) Assess the client’s lung sounds and oxygenation Rationale: A new cough may be a side effect of lisinopril or a sign of worsening heart failure. Assessment of respiratory status is the priority before taking further action. A nurse is caring for a client with a non-healing arterial lower leg ulcer. What action by the nurse is best? A) Clean the ulcer with sterile water B) Apply a hydrocolloid dressing C) Consult with the wound care nurse D) Encourage ambulation Correct Answer: C) Consult with the wound care nurse Rationale: Non-healing arterial ulcers require specialized management; referral to a wound care nurse ensures optimal treatment. A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? A) “I will walk every day to improve circulation.” B) “I should avoid crossing my legs.” C) “I can use a heating pad on my legs if it’s set on low.” D) “I should inspect my feet daily.” Correct Answer: C) “I can use a heating pad on my legs if it’s set on low.” Rationale: Clients with PAD have impaired circulation and sensation; heating devices can cause burns and must be avoided.
The nurse is assessing a client on admission to the hospital. The client’s leg is swollen, red, blistered, and the great toe is black and necrotic. What action by the nurse is best? A) Apply a warm compress to the leg B) Elevate the leg above heart level C) Assess the client’s ankle-brachial index D) Apply compression stockings Correct Answer: C) Assess the client’s ankle-brachial index Rationale: The ankle-brachial index measures arterial perfusion, which is critical to determine in the presence of necrosis and PAD signs. A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first? A) Assess airway patency B) Assess for facial bruising C) Check for nasal deformity D) Assess for nosebleed Correct Answer: A) Assess airway patency Rationale: Airway assessment always takes priority in trauma situations such as nasal fractures. A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, headache, and difficulty with vision. What action would the nurse take next? A) Apply a nasal clamp B) Collect the nasal drainage on a piece of filter paper C) Administer prescribed analgesics D) Place the client in supine position Correct Answer: B) Collect the nasal drainage on a piece of filter paper Rationale: Drainage must be tested for cerebrospinal fluid leakage, a possible complication of nasal or skull fracture. A nurse teaches a client who had a supraglottic laryngectomy. What technique would the nurse teach the client to prevent aspiration? A) Swallow three times without breathing B) Swallow twice while bearing down C) Tilt head forward while swallowing D) Drink fluids through a straw
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond? A) “This is normal after surgery. What types of food do you like to eat?” B) “You need to report this to the surgeon immediately.” C) “Add more salt and spices to your meals.” D) “This means you are developing an infection.” Correct Answer: A) “This is normal after surgery. What types of food do you like to eat?” Rationale: Altered taste sensation is common after laryngectomy. Reassurance and encouragement promote nutrition and recovery. A nurse cares for a client who is scheduled for a total laryngectomy. What action would the nurse take prior to surgery? A) Assess the client’s airway B) Assist the client to choose a communication method C) Provide preoperative antibiotics D) Encourage coughing and deep breathing exercises Correct Answer: B) Assist the client to choose a communication method Rationale: Total laryngectomy removes the vocal cords, so preoperative planning for alternative communication is essential. While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. What action would the nurse take first? A) Administer oxygen via nasal cannula B) Contact the primary health care provider and prepare for intubation C) Reassure the client D) Place the client in a semi-Fowler’s position Correct Answer: B) Contact the primary health care provider and prepare for intubation Rationale: Stridor indicates airway obstruction. Immediate airway management is the priority. A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first? A) Provide ice chips B) Assess the client’s airway C) Administer prescribed antibiotics D) Elevate the head of the bed
Correct Answer: B) Assess the client’s airway Rationale: Nasal packing can obstruct breathing. Airway assessment takes priority over all other interventions. A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement would the nurse include in this patient’s teaching? A) “Make sure you clean the humidifier to relax the airway.” B) “The humidifier will reduce the need for suctioning.” C) “The humidifier keeps secretions thin and moist.” D) “Use the humidifier only at night.” Correct Answer: C) “The humidifier keeps secretions thin and moist.” Rationale: Humidification prevents mucus plugging and promotes airway clearance after laryngectomy. A nurse is caring for a client who had a modified uvulopalatopharyngoplasty earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met? A) Client denies pain B) Client is able to swallow own secretions without drooling C) Client’s oxygen saturation is 92% D) Client is drowsy but arousable Correct Answer: B) Client is able to swallow own secretions without drooling Rationale: Being able to swallow secretions indicates an intact airway and reduced aspiration risk, the priority after this surgery. A nurse assesses several clients who have a history of respiratory disorders. Which client would the nurse assess first? A) A 45-year-old with stable asthma B) A 27-year-old client with a heart rate of 120 beats/min C) A 60-year-old with COPD on 2 L oxygen D) A 35-year-old with allergic rhinitis Correct Answer: B) A 27-year-old client with a heart rate of 120 beats/min Rationale: Tachycardia may indicate hypoxemia or worsening respiratory distress, requiring immediate attention.
B) “I will use the drug when I have an asthma attack.” C) “This drug helps prevent asthma symptoms.” D) “I will continue to carry my rescue inhaler.” Correct Answer: B) “I will use the drug when I have an asthma attack.” Rationale: Salmeterol is a long-acting drug and must not be used for acute asthma attacks. Rescue inhalers are for emergencies. A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that going out with friends is no longer enjoyable. How would the nurse respond? A) “You should avoid social gatherings to reduce infection risk.” B) “I’d like to hear about thoughts and feelings causing you to limit social activities.” C) “Increase your oxygen flow rate before going out.” D) “It’s best to rest at home to conserve energy.” Correct Answer: B) “I’d like to hear about thoughts and feelings causing you to limit social activities.” Rationale: This response addresses psychosocial needs and encourages open communication, promoting coping strategies. A nurse assesses a client who is prescribed fluticasone and notes oral lesions. What action would the nurse take? A) Discontinue the medication immediately B) Encourage oral rinsing after fluticasone administration C) Apply antifungal cream to the lesions D) Switch to a rescue inhaler Correct Answer: B) Encourage oral rinsing after fluticasone administration Rationale: Fluticasone can cause oral candidiasis. Rinsing the mouth prevents fungal infections. A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take? A) Encourage coughing and deep breathing despite the pain B) Administer pain medication and encourage the client to take deep breaths C) Clamp the chest tube temporarily D) Reduce suction pressure Correct Answer: B) Administer pain medication and encourage the client to take deep breaths
Rationale: Adequate pain control promotes lung expansion and prevents complications like pneumonia or atelectasis. A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process would the nurse correlate with this client’s history and clinical signs and symptoms? A) Left ventricular failure B) Increased pulmonary pressure creating a higher workload on the right side of the heart C) Obstructive sleep apnea D) Pulmonary embolism Correct Answer: B) Increased pulmonary pressure creating a higher workload on the right side of the heart Rationale: Chronic smoking often leads to cor pulmonale (right-sided heart failure) due to pulmonary hypertension, manifesting as JVD and peripheral edema. A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? - best ans-Use of multiple herbs and supplements A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for postdischarge care? - best ans-Older adult who lives alone at home despite some memory loss A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot fo what is said, and asks the same questions again and again. What action by the nurse is best? - best ans-Assess the client for anxiety A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? - best ans-Potassium
An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by
A client had a surgical procedure with spinal anesthesia. The client's blood pressure was 122/ mm Hg 30 minutes ago and is now 138/60 and the client reports nausea. What action by the nurse is best? - best ans-Notify the primary health care provider A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? - best ans-Auscultate lungs sounds A postoperative client has just been admitted to the (PACU). What assessment by the PACU nurse takes priority? - best ans-Airway A postoperative client has respiratory depression after receiving morphine for pain. Which medication and dose does the nurse prepare to administer? - best ans-Naloxone 0.4 to 2 mg A nurse on the post surgical inpatient unit is observing a client perform leg exercises. What action by the client indicates a need for further instruction? - best ans-Bends both knees, pushes against the bed until calf and thigh muscles contract A registered nurse (RN) is watching a new nurse change a dressing and perform care around a Penrose drain. What action by the new nurse warrants intervention? - best ans-Securing the drain's safety pin to the sheets A postoperative nurse is caring for a client who received a neuromuscular blocking agent during surgery. On assessment the nurse notes the client has weak hand grasps. What assessment does the nurse conduct next? - best ans-Signs of oxygenation The PACU nurse is caring for an older client following a lengthy surgery. The client's pulse is 48 beats/min which is 20 beats/min lower than the preoperative baseline. What assessment does the nurse make next? - best ans-Temperature
The postoperative nurse is caring for a client who reports feeling "something popped" after vomiting. What action by the nurse is best? - best ans-Gather sterile nonadherent dressing A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse would cause the supervising nurse to intervene? - best ans-Palpating both carotid arteries at the same time The nurse is evaluating a 3 day diet history with a client who has an elevated lipid panel. What meal selection indicates that the client is managing this condition we'll with diet? - best ans- Baked chicken breast, broccoli, tomatoes A nurse is working with a client who takes clopridogrel. The client's recent laboratory results include a BUN of 33 mg/dl and creatinine of 2.8 mg/dl. What action by the nurse is best? - best ans-Ask if the client eats grapefruit A client 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? - best ans- "Most people with hypertension do not have symptoms" A client asks what "essential hypertension" is. What response by the registered nurse is best? - best ans-"it is hypertension with no specific cause" 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? - best ans-African-American churches A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? - best ans-Assist in finding one change the client can control
A nurse cares for a client who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment? - best ans-Keep padded clamps at the bedside for use if the drainage system is interrupted Which is the most common intrarenal cause of acute kidney injury? - best ans-Acute tubular necrosis The creation of arteriovenous access for hemodialysis causes - best ans-arterial blood to shift to other areas, which can lead to vascular insufficiency Condition is called 'steel syndrome' The nurse must monitor for which condition in patients with bilateral ureteral obstruction? - best ans-Bilateral ureteral obstruction results in dilation of the kidneys, which is called hydronephrosis. Hydronephrosis, if left untreated, can result in acute kidney injury (AKI). Which is a manifestation of a mild form of acute kidney injury? - best ans-increaed serum creatinine characteristics of a severe form of acute kidney injury? - best ans-Increased levels of potassium and nitrogen A patient is recovering in the intensive care unit (ICU) after receiving a kidney transplant approximately 24 hours ago. What is an expected assessment finding for this patient during this early stage of recovery? - best ans-diuresis (a large volume of urine output) in the hours and days immediately following a kidney transplant When assessing the mental status of a patient in acute renal failure, the nurse recognizes that abnormal findings are most likely caused by what? - best ans-Confusion related to an increased urea level
In renal disease, urea is not filtered out of the blood by the kidneys and therefore accumulates in the blood. This results in toxicity to brain tissue, causing confusion. Which patient is most likely to develop chronic kidney disease (CKD) and should be taught preventive measures by the nurse? - best ans-Teach CKD prevention to the 61-year-old Native American with diabetes. This patient is at highest risk because diabetes causes about 50% of CKD. This patient is the oldest, and Native Americans with diabetes develop CKD six times more frequently than other ethnic groups. Hypertension causes about 25% of CKD. Hispanics have CKD about 1.5 times more than non- Hispanics. African Americans have the highest rate of CKD because hypertension is increased significantly in African Americans. Which nursing intervention is appropriate for a patient during the oliguric phase of an acute kidney injury (AKI)? - best ans-Mouth care Patients with acute kidney injury experience mucous membrane irritation caused by the production of ammonia in the saliva. Therefore the nurse should provide frequent oral care to prevent stomatitis Which process involves movement of fluid and molecules across a semipermeable membrane from one compartment to another? - best ans-dialysis Dialysis is the movement of fluid and molecules across a semipermeable membrane from one compartment to another. Substances move from the blood through a semipermeable membrane and into a dialysis solution in this process Which nursing intervention should the nurse implement while preparing a high-risk patient with contrast-induced nephropathy for magnetic resonance imaging? - best ans-HYDRAATE WITH PLENTY OF FLUIDS
measurements, insert IV lines, or perform venipuncture in the extremity with vascular access. These special precautions are taken to prevent infection and clotting of the vascular access site. A patient is scheduled to undergo peritoneal dialysis. What is the highest-priority action that the nurse should perform before starting dialysis? - best ans-check the patient's weight before and after peritoneal dialysis (PD) to determine how much fluid has been removed. Which clinical action plan is most appropriate for a patient in stage 3 of chronic kidney disease?
- best ans-Evaluation and treatment of complications Evaluation and treatment of complications During hemodialysis, the patient develops light-headedness and nausea. What is the priority action by the nurse? - best ans-The rate and volume of fluid removal will be decreased, and 0.9% saline solution may be infused. The nurse reviews lab tests that have been prescribed for a patient in acute renal failure. Which is the best indicator of renal function? - best ans-creatinine Creatinine is a waste product of the skeletal muscles and is excreted through the kidneys. In renal failure, the kidneys are unable to excrete creatinine, leading to a serum level greater than the normal range of 0.2 to 1.0 mL/dL. A nurse planning care for a patient with acute renal failure recognizes that the interventions of highest priority are directly related to what? - best ans-excess fluid volume is the primary problem of acute renal failure and the highest priority for the nurse in this situation. The major problem with acute renal failure is altered fluid and electrolytes, which, if not managed, can lead to permanent renal damage, cardiac complications, and death. Continuous Renal Replacement Therapy (CRRT) - best ans-type of renal replacement therapy used to treat patients with acute kidney injury, particularly those with multiple organ failure; the types of patients treated tend to be hemodynamically unstable, have poor cardiac output, and be unable to tolerate hemodialysis
The blue catheter lumen returns blood from the dialyzer back to the patient in CRRT. The hemofilter used in CRRT should be changed every 24 to 48 hours to retain maximum filtration efficacy. Red cath withdraws blood the nurse suspects that which electrolyte abnormality is the cause of edema in a patient with chronic kidney disease? - best ans-HypoNATREMIA Improper functioning of the kidneys impairs sodium excretion, which leads to sodium and water retention resulting in edema What causes prerenal acute kidney injury - best ans-a reduced flow of blood to the kidneys What can cause intrarenal acute kidney injury - best ans-A release of nephrotoxins is an intrarenal cause of acute kidney injury. What is a postrenal cause of acute kidney injury - best ans-Urine reflux into the renal pelvis and the presence of extrarenal tumors glomerular filtration rate is decreased with inflammation and injury to the glomeruli .... as seen by - best ans-inflammation and injury to the glomeruli, resulting in fluid retention, hypertension, and decreased filtration of metabolic waste products from the blood as seen by findings of periorbital and peripheral edema. result of glomerular injury. - best ans-hematuria & proteinuria care for acute poststreptococcal glomerulonephritis w/AKI - best ans-Administer antihypertensives
