Adult Health Exam

Question 1

Adult Health Exam. The nurse is assessing a client admitted for a fracture of the left tibia, who has a splint on the left leg. The client reports numbness in the left foot. What priority action should the nurse perform?

Send the client for a lower extremity ultrasound.
Complete a neurovascular assessment of the left leg.
Loosen and reposition the lower extremity splint.
Elevate and apply ice to the left lower extremity.

Question 27

The nurse is reviewing the laboratory results of a client with a suspected myocardial infarction (MI). Which laboratory value is most specific for myocardial damage?

Troponin I
Creatine kinase (CK)
Myoglobin
White blood cell (WBC) count

Question 28

Which assessment finding is most important for the nurse to report to the healthcare provider for a client who had a cardiac catheterization 2 hours ago?

A pedal pulse that is weaker than the pre-procedure baseline
Pain at the insertion site rated at 3 out of 10
A heart rate of 92 beats per minute
Urinary output of 100 mL over the last 2 hours

Question 29

A client is admitted with deep vein thrombosis (DVT) in the right leg. Which nursing intervention should be included in the plan of care?

Apply an ice pack to the affected area every 4 hours
Monitor the client for sudden onset of shortness of breath
Massage the right calf once per shift to improve circulation
Encourage the client to ambulate around the unit frequently

Question 30

The nurse is preparing to administer digoxin to a client with heart failure. Which action should the nurse take first?

Check the client’s latest potassium level
Assess the apical pulse for one full minute
Monitor the client’s blood pressure
Review the most recent digoxin level

Question 31

Which statement by a client with hypertension indicates a need for further teaching about the DASH diet?

“I will incorporate more fresh fruits and vegetables into my meals.”
“I should choose whole-grain breads instead of white bread.”
“I can use canned vegetables to save time as long as I don’t add extra salt.”
“I will limit my intake of red meats and sugary sweets.”Adult Health Exam.

Question 32

A nurse is assessing a client with peripheral arterial disease (PAD). Which finding is expected with this condition?

Edema around the ankles
Pain in the legs that occurs during exercise and is relieved by rest
Brownish discoloration of the skin on the lower legs
Warm, reddened skin on the feet

Question 33

The nurse is monitoring a client receiving a blood transfusion. After 15 minutes, the client reports back pain and itching. What is the priority nursing action?

Stop the blood transfusion immediately
Notify the healthcare provider and the blood bank
Administer diphenhydramine as prescribed
Check the client’s vital signs and re-verify the unit of blood

Question 34

Which clinical manifestation should the nurse expect to find in a client diagnosed with right-sided heart failure?

Pulmonary crackles
Dyspnea on exertion
Jugular venous distention (JVD)
Orthopnea

Question 35

A client with atrial fibrillation is being discharged on warfarin. Which instruction should the nurse include in the discharge teaching?

“Increase your intake of leafy green vegetables to prevent bleeding.”
“You can take aspirin for headaches while on this medication.”
“Use an electric razor and a soft-bristled toothbrush.”
“If you miss a dose, double the next dose to stay on schedule.”

Question 36

The nurse is caring for a client with a permanent pacemaker. Which activity should the nurse instruct the client to avoid?

Using a microwave oven
Standing near anti-theft devices in stores for long periods
Traveling by airplane
Using a cellular phone on the ear opposite the pacemaker site

Question 37

Which client should the nurse assess first after receiving the shift report?

A client with heart failure who has 2+ pitting edema in the lower extremities
A client with a history of deep vein thrombosis who reports sudden chest pain and dyspnea
A client with hypertension whose blood pressure is 158/92 mmHg
A client with end-stage renal disease who is waiting for scheduled dialysis

Question 38

A client is admitted with a diagnosis of acute pericarditis. Which assessment finding should the nurse expect?

Chest pain that is relieved by leaning forward
A systolic murmur heard best at the apex
Pitting edema in the bilateral lower extremities
Bradycardia with a heart rate of 52 beats per minute

Question 39

The nurse is providing education to a client with Raynaud’s phenomenon. Which instruction is most important to include?

“Protect your hands and feet from cold temperatures.”
“Apply ice packs to your fingers when they turn white.”
“Avoid all forms of physical exercise.”
“Soak your hands in hot water for 30 minutes daily.”

Question 40

Which laboratory result requires immediate notification of the healthcare provider for a client receiving a continuous heparin infusion?

Prothrombin time (PT) of 12 seconds
International Normalized Ratio (INR) of 1.1
Platelet count of 90,000/mm³
Activated partial thromboplastin time (aPTT) of 65 seconds

Question 41

A client with chronic venous insufficiency is being discharged. Which self-care measure should the nurse emphasize?

“Wear compression stockings as prescribed.”
“Sit with your legs in a dependent position for long periods.”
“Limit your fluid intake to 1 liter per day.”
“Avoid walking to prevent further leg damage.”

Question 42

The nurse is assessing a client for the Presence of Homan’s sign. Which action should the nurse perform?

Ask the client to stand and march in place
Dorsiflex the client’s foot and ask about calf pain
Palpate the popliteal pulse for strength
Percuss the client’s tibia for tenderness

Question 43

Which medication is typically prescribed for a client experiencing an acute episode of angina pectoris?

Furosemide
Nitroglycerin
Metoprolol
Lisinopril

Question 44

A client is diagnosed with Buerger’s disease (thromboangiitis obliterans). Which lifestyle modification is essential for the client to follow?

Complete cessation of tobacco use
Adoption of a high-protein diet
Reducing daily physical activity
Taking daily vitamin C supplements

Question 45

What is the most serious complication of an abdominal aortic aneurysm (AAA)?

Infection of the vessel wall
Rupture of the aneurysm
Development of deep vein thrombosis
Gradual narrowing of the vessel

Question 46

The nurse is caring for a client with infective endocarditis. Which assessment finding is a classic sign of this condition? Adult Health Exam.

Pleuritic chest pain
Splinter hemorrhages in the nail beds
Absent pedal pulses
Symmetrical facial drooping

Question 47

A nurse is preparing to administer sublingual nitroglycerin. What should the nurse tell the client to expect?

A tingling or burning sensation under the tongue
Immediate drowsiness and sedation
Sudden increase in appetite
Temporary loss of taste

Question 48

Which food choice is most appropriate for a client on a low-sodium diet?

Cured ham
Pickled beets
Fresh baked chicken breast
Low-fat cottage cheese

Question 49

The nurse is monitoring a client’s EKG strip and notes a saw-tooth pattern. Which rhythm is the client likely experiencing?

Ventricular fibrillation
Sinus tachycardia
Atrial flutter
First-degree AV block

Question 50

Which sign or symptom is indicative of a developing pulmonary embolism in a postoperative client?

Sudden onset of shortness of breath and chest pain
Productive cough with green sputum
Gradual increase in blood pressure
Numbness in the fingers and toes Adult Health Exam.

Question 63

Which nursing intervention should the nurse implement to help prevent postoperative complications of deep vein thrombosis (DVT), constipation and abdominal distention?

Turn, cough, and deep breathe q2h
Progress diet slowly, start with clear liquids
Apply sequential compression devices
Ambulate in halls three times a day

Question 64

The nurse is teaching a client with type 2 diabetes about situations that could necessitate insulin injections. Under which circumstances might a client on oral agents have to take insulin? (Select all that apply).

If the client is hospitalized
If oral meds don’t control blood sugar
If the client eats a large meal
During periods of stress
If the client’s A1C falls below 5.0%
During periods of illness

Question 65

What information should be provided to a client who is newly diagnosed with type 1 diabetes? Select all that apply.

Symptoms of hypoglycemia
Avoid exercising while taking insulin
Take insulin consistently, even when feeling sick
Monitoring and recording blood glucose
Proper timing of meals
Proper timing of oral diabetic medications

Question 66

Which intervention(s) would most effectively support communication with a client who has global aphasia following a stroke? Select all that apply.

Speak in a loud and deliberate voice to the client.
Have the client speak to loved ones on the phone daily.
Provide a board of commonly used needs and phrases.
Speak clearly and in an unhurried manner
Help the client complete their own sentences.
Regularly communicate with the client during care activities.

Question 67

A client is scheduled to receive a nerve block for surgery on their left arm. What information should the nurse include when teaching about this type of anesthesia?

You will be unconscious during the surgery
You will be numb from the waist up prior to surgery
You will be able to talk to the provider during surgery
You will have increased pain during the surgery

Question 68

A client with a new diagnosis of heart failure has received self-care education. Which statement by the client prompts the nurse to provide additional education?

“I will limit my intake of foods high in sodium such as processed meats.”
“I should weigh myself every evening before bed without clothes on.”
“Taking my prescribed medications can slow the progression of heart failure.”
“I need to notify my healthcare provider if I gain 2-3 pounds in one day.”

Question 69

A client with type 2 diabetes has developed numbness and tingling in both feet. What nursing intervention is the most effective in preventing complications from this condition?

Teach the client to keep blood glucose within target range
Inspect the client’s feet during annual exams only
Instruct the client to apply compression stockings.
Teach the client to wear open toed shoes

Question 70

Vancomycin 1 gram in 250 mL normal saline is ordered to infuse over 90 minutes via IV piggyback. What rate will the nurse set the pump? ______ mL/hr Round to the tenths place.

166.7

Question 71

A client is ordered to receive a heparin infusion at 13 units/kg/hr. Heparin is supplied 25,000 units/250 mL 1/2 NS. The patient weighs 175 pounds. What rate will the nurse set the pump? ______ mL/hr. Round to the tenths place.

10.3

Question 72

A client is to receive gentamicin 60 mg in normal saline 100 mL IV every 8 hours, to infuse over 60 minutes. How many drops per minute do you set on gravity tubing that has a drop factor of 10 gtts/mL? __gtt/min (Round to a whole number)

Question 73

A client has been told the tumor in their bowel is poorly differentiated. What is the most accurate description of poorly differentiated cells?

These cells are frequently an indication of malignant neoplasms.
These cells readily respond to treatment.
These cells usually respond to the body’s natural defense mechanisms.
These cells maintain the structure and function of the tissue of origin.

Question 74

What is the primary purpose of change-of-shift report? Adult Health Exam.

discuss education needs for the client.
provide for continuity of nursing care.
share the physical therapy schedule for the day.
identify lab tests waiting to be completed.

Question 75

When caring for a client receiving t-PA for an ischemic stroke, which potential complication requires immediate nursing attention?

Seizures
Bleeding
Acute pain
Septicemia

Question 76

The nurse is caring for a client whose blood pressure unexpectedly dropped to 78/47 mmHg. The registered nurse (RN) asks the unlicensed assistive personnel (UAP) to stay with the client and check vital signs every 5 minutes. Which statement about this delegation is most accurate?

The delegation is appropriate when the RN provides clear parameters.
Checking vital signs for an unstable client is within the scope of practice.
The RN must ensure that the UAP is unsupervised while performing this task.
This was not an appropriate task to delegate to the UAP.

Question 77

Which client(s) would be at highest risk of an embolic ischemic stroke? (Select all that apply) Adult Health Exam.

A 75-year-old client with congestive heart failure and reduced ejection fraction
A 65-year-old client with implanted pacemaker and history of paroxysmal atrial fibrillation
A 60-year-old client with stable angina and no history of arrhythmias
A 72-year-old client with atrial fibrillation and a history of heart valve replacement
A 70-year-old client with uncontrolled hypertension and left atrial enlargement
A 68-year-old client with recent myocardial infarction and left ventricular thrombus

Question 78

The registered nurse (RN) delegated ambulation of a client to the unlicensed assistive personnel (UAP). At the end of the shift, the RN learns the client was not ambulated because the UAP was busy with other clients. Who is ultimately accountable for failure to ambulate the client?

Only the RN
Neither; ambulation is to be performed by physical therapy
Only the UAP
Both the RN and the UAP

Question 79

A physician prescribes clopidogrel (Plavix) for a client with cerebral atherosclerosis. What is an expected outcome of this drug?

regulation of their elevated blood pressure.
prevention of platelet aggregation around atherosclerotic plaques.
breakdown of clots that have formed in their cerebral arteries.
healing of sites where blood is leaking out of their cerebral arteries.

Question 80

When the client is receiving patient-controlled analgesia (PCA) therapy, which medication should be readily available for adverse reactions?

Vitamin K
Protamine sulfate
Naloxone (Narcan)
Flumazenil (Romazicon)

Adult Health Exam

Isaura K

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