Care of the Adult Exam

Question 1

Care of the Adult 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 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

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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

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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.”

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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

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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.”

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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

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Question 43

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

• Furosemide
• Nitroglycerin
• Metoprolol
• Lisinopril

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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

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Question 45

Care of the Adult Exam. 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

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Question 46

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

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

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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

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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

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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

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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