FOCUS ON ADULT HEALTH
ACTUAL EXAM WITH
DETAILED VERIFIED
ANSWERS AND
RATIONALES\ALREADY
GRADED A+\VERIFIED BY
EXPERT
A nurse is developing a plan of care for a client who has had a stroke and is experiencing
homonymous hemianopsia. Which interventions does the nurse include in the care plan to help the
client to overcome this deficit?
Encouraging the client to turn the head from side to side to scan the complete range of vision
Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous
hemianopsia should have objects placed in the intact field of vision, and the nurse should approach the
client from the intact side. The nurse instructs the client to scan the environment to overcome the visual
deficit and conducts client teaching from within the intact field of vision. The nurse encourages the use
of the client's own eyeglasses, if they are available. Discouraging the client from using a walker when
ambulating and teaching the client to perform active range-of-motion exercises are unrelated to this
deficit.
An antibiotic mixed in 100 mL of normal saline solution is to be administered over half an hour. The
drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round
your answer to the nearest whole number.)
33
Hepatitis A vaccine is prescribed for a client who is planning a trip out of the country. The nurse tells
the client that:
,A booster dose is needed 6 to 12 months after the initial injection
Rationale: Hepatitis A vaccine contains inactivated hepatitis A virus. A single dose of this vaccine is given
intramuscularly; a booster dose is administered 6 to 12 months after the initial injection. Active
immunity to hepatitis B is provided by the hepatitis B vaccine (Engerix-B, Recombivax-HB). Hepatitis A
vaccine is not available in an oral form.
A nurse is reviewing laboratory results for a client who has been taking digoxin for the treatment of
heart failure. The nurse notes that the report indicates a serum digoxin level of 0.8 ng/mL (1.02
nmol/L). The nurse would most appropriately:
Document the laboratory result
Rationale: The optimal therapeutic serum digoxin range is 0.5 to 0.8 ng/mL (0.64 to 1.02 nmol/L).. A
level of 0.8 ng/mL (1.02 nmol/L) is within the therapeutic range. Therefore the nurse would document
the laboratory result. Contacting the health care provider, repeating the test, and monitoring the client
for signs of toxicity are not necessary at this time, because the result is normal.
A client has been taking pyrazinamide (PMS Pyrazinamide) for 2 months. Which culture result does
the nurse monitor as an indicator that the medication may soon be discontinued?
Sputum
Rationale: Pyrazinamide is an antitubercular medication that is given in conjunction with other
antitubercular medications. The prescriber may discontinue its use if sputum cultures become negative.
Urine, blood, and wound cultures are not associated with the use of this medication.
A client is receiving heparin sodium by way of continuous intravenous (IV) infusion. For which adverse
effect of this therapy does the nurse monitor the client? Select all that apply.
Petechiae
Hematuria
Tarry stools
Rationale: The client who receives continuous IV heparin is at risk for bleeding. The nurse assesses the
client for signs of bleeding, including bleeding from the gums, petechiae, ecchymoses on the skin, cloudy
or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. Tinnitus, hematuria,
and increased pulse rate are not side effects of this medication.
Cyclophosphamide is prescribed for a client with a diagnosis of breast cancer. The nurse has provided
instructions to the client regarding the medication. Which statement by the client indicates an
understanding of this chemotherapeutic regimen?
"I need to increase my fluid intake to 2000 to 3000 mL a day."
Rationale: Hemorrhagic cystitis is a toxic effect of cyclophosphamide. The client should be instructed to
drink copious amounts of fluid while taking this medication and should also monitor the urine blood.
The medication should be taken on an empty stomach unless gastrointestinal upset occurs.
, Hyperkalemia may result from the use of the medication; therefore the client would not be encouraged
to increase potassium intake (i.e., bananas, orange juice). The client would not be instructed to alter her
sodium intake.
A nurse is caring for a client who has been fitted with a continuous bladder irrigation system. During
the nurse's 8-hour shift, total infusion of bladder irrigant is 1075 mL. At the end of the 8-hour shift,
the nurse calculates that 2050 mL of output was emptied from the Foley catheter drainage bag. How
many milliliters of true urine output does the nurse document?
975
Rationale: If the total volume emptied from the Foley catheter was 2050 mL and 1075 mL was bladder
irrigant, the amount of true urine was 975 mL. To obtain this answer, you must subtract 1075 mL of
bladder irrigant from the total emptied (2050 mL).
Cefuroxime axetil 1 g in 50 mL of normal saline solution, is to be administered over 30 minutes. The
drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate?
25
A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the client's
laboratory results and notes that the client has thrombocytopenia. Which interventions does the
nurse implement when caring for the client? Select all that apply.
Inspecting all stools for occult blood Correct
Measuring the client's abdominal girth every day
Providing the client with an electric razor for shaving
Avoiding the administration of intramuscular injections
Rationale: A client who has thrombocytopenia is at risk for bleeding, and interventions are aimed at
protecting the client from injury and detecting bleeding so that appropriate interventions may be
initiated. The nurse should inspect all stools, urine, drainage, and vomit for blood and test them for
occult blood. The abdominal girth is measured daily because increases in abdominal girth may indicate
internal hemorrhage. As a means of reducing the risk of bleeding, intramuscular injections, which can
cause trauma to the tissues and result in hematoma formation, are avoided. Additionally, an electric
razor is used. The incorrect interventions for this question would be implemented if the client had a low
white blood cell or neutrophil count and was at risk for infection.
A client is using diphenhydramine 1% as a topical agent to treat allergic dermatosis. Which outcome
indicates to the nurse that the medication is having the intended effect?
Relief of urticaria
Rationale: Diphenhydramine is an antihistamine medication that has many uses. When used as a topical
agent on the skin, it reduces the symptoms of allergic reaction, such as itching or urticaria. It does not
act to relieve pain, headache, or skin redness.
ACTUAL EXAM WITH
DETAILED VERIFIED
ANSWERS AND
RATIONALES\ALREADY
GRADED A+\VERIFIED BY
EXPERT
A nurse is developing a plan of care for a client who has had a stroke and is experiencing
homonymous hemianopsia. Which interventions does the nurse include in the care plan to help the
client to overcome this deficit?
Encouraging the client to turn the head from side to side to scan the complete range of vision
Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous
hemianopsia should have objects placed in the intact field of vision, and the nurse should approach the
client from the intact side. The nurse instructs the client to scan the environment to overcome the visual
deficit and conducts client teaching from within the intact field of vision. The nurse encourages the use
of the client's own eyeglasses, if they are available. Discouraging the client from using a walker when
ambulating and teaching the client to perform active range-of-motion exercises are unrelated to this
deficit.
An antibiotic mixed in 100 mL of normal saline solution is to be administered over half an hour. The
drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round
your answer to the nearest whole number.)
33
Hepatitis A vaccine is prescribed for a client who is planning a trip out of the country. The nurse tells
the client that:
,A booster dose is needed 6 to 12 months after the initial injection
Rationale: Hepatitis A vaccine contains inactivated hepatitis A virus. A single dose of this vaccine is given
intramuscularly; a booster dose is administered 6 to 12 months after the initial injection. Active
immunity to hepatitis B is provided by the hepatitis B vaccine (Engerix-B, Recombivax-HB). Hepatitis A
vaccine is not available in an oral form.
A nurse is reviewing laboratory results for a client who has been taking digoxin for the treatment of
heart failure. The nurse notes that the report indicates a serum digoxin level of 0.8 ng/mL (1.02
nmol/L). The nurse would most appropriately:
Document the laboratory result
Rationale: The optimal therapeutic serum digoxin range is 0.5 to 0.8 ng/mL (0.64 to 1.02 nmol/L).. A
level of 0.8 ng/mL (1.02 nmol/L) is within the therapeutic range. Therefore the nurse would document
the laboratory result. Contacting the health care provider, repeating the test, and monitoring the client
for signs of toxicity are not necessary at this time, because the result is normal.
A client has been taking pyrazinamide (PMS Pyrazinamide) for 2 months. Which culture result does
the nurse monitor as an indicator that the medication may soon be discontinued?
Sputum
Rationale: Pyrazinamide is an antitubercular medication that is given in conjunction with other
antitubercular medications. The prescriber may discontinue its use if sputum cultures become negative.
Urine, blood, and wound cultures are not associated with the use of this medication.
A client is receiving heparin sodium by way of continuous intravenous (IV) infusion. For which adverse
effect of this therapy does the nurse monitor the client? Select all that apply.
Petechiae
Hematuria
Tarry stools
Rationale: The client who receives continuous IV heparin is at risk for bleeding. The nurse assesses the
client for signs of bleeding, including bleeding from the gums, petechiae, ecchymoses on the skin, cloudy
or pink-tinged urine, tarry stools, and body fluids that test positive for occult blood. Tinnitus, hematuria,
and increased pulse rate are not side effects of this medication.
Cyclophosphamide is prescribed for a client with a diagnosis of breast cancer. The nurse has provided
instructions to the client regarding the medication. Which statement by the client indicates an
understanding of this chemotherapeutic regimen?
"I need to increase my fluid intake to 2000 to 3000 mL a day."
Rationale: Hemorrhagic cystitis is a toxic effect of cyclophosphamide. The client should be instructed to
drink copious amounts of fluid while taking this medication and should also monitor the urine blood.
The medication should be taken on an empty stomach unless gastrointestinal upset occurs.
, Hyperkalemia may result from the use of the medication; therefore the client would not be encouraged
to increase potassium intake (i.e., bananas, orange juice). The client would not be instructed to alter her
sodium intake.
A nurse is caring for a client who has been fitted with a continuous bladder irrigation system. During
the nurse's 8-hour shift, total infusion of bladder irrigant is 1075 mL. At the end of the 8-hour shift,
the nurse calculates that 2050 mL of output was emptied from the Foley catheter drainage bag. How
many milliliters of true urine output does the nurse document?
975
Rationale: If the total volume emptied from the Foley catheter was 2050 mL and 1075 mL was bladder
irrigant, the amount of true urine was 975 mL. To obtain this answer, you must subtract 1075 mL of
bladder irrigant from the total emptied (2050 mL).
Cefuroxime axetil 1 g in 50 mL of normal saline solution, is to be administered over 30 minutes. The
drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate?
25
A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the client's
laboratory results and notes that the client has thrombocytopenia. Which interventions does the
nurse implement when caring for the client? Select all that apply.
Inspecting all stools for occult blood Correct
Measuring the client's abdominal girth every day
Providing the client with an electric razor for shaving
Avoiding the administration of intramuscular injections
Rationale: A client who has thrombocytopenia is at risk for bleeding, and interventions are aimed at
protecting the client from injury and detecting bleeding so that appropriate interventions may be
initiated. The nurse should inspect all stools, urine, drainage, and vomit for blood and test them for
occult blood. The abdominal girth is measured daily because increases in abdominal girth may indicate
internal hemorrhage. As a means of reducing the risk of bleeding, intramuscular injections, which can
cause trauma to the tissues and result in hematoma formation, are avoided. Additionally, an electric
razor is used. The incorrect interventions for this question would be implemented if the client had a low
white blood cell or neutrophil count and was at risk for infection.
A client is using diphenhydramine 1% as a topical agent to treat allergic dermatosis. Which outcome
indicates to the nurse that the medication is having the intended effect?
Relief of urticaria
Rationale: Diphenhydramine is an antihistamine medication that has many uses. When used as a topical
agent on the skin, it reduces the symptoms of allergic reaction, such as itching or urticaria. It does not
act to relieve pain, headache, or skin redness.
