Adult 1 Exam 1 Questions With Complete Solutions
A client had a 20-gauge short peripheral catheter (SPC) inserted
for antibiotic administration 48 hours ago. Which nursing
intervention is appropriate?
a. Discontinue the SPC
b. Relocated the SPC for infection control.
c. Assess the SPC for redness, swelling, or pain.
d. Change the occlusive dressing covering the SPC. Correct
Answers C
A client has just come to the floor after undergoing inner
maxillary fixation for a mandibular fracture with wiring of the
jaws. As the nurse raises the head of the bed, the client starts to
vomit a large amount of liquid vomitus. What is the nurse's
priority action?
a. Administer the prescribed antiemetic by the intravenous or
rectal route.
b. Immediately notify the surgeon, the anesthesiologist, or the
rapid response team.
c. Cut the wires holding his jaws together, and carefully remove
them from the mouth.
d. Reposition the client to the side and suction the mouth with a
large-bore catheter. Correct Answers D
A client newly diagnosed with stage I nonsmall cell lung cancer
(NSCLC) who is getting ready for curative surgery ask the nurse
whether the oncologist might consider this new drug he has seen
on television, pembrolizumab, instead of surgery. What is the
nurse's best response?
,a. "This drug will only work on those lung cancers that have the
right target and your tumor does not have it."
b. "This drug is approved for use in clients whose lung cancer
has metastasized not for early-stage cancers."
c. "Why would you want to take a drug for months when you
may be cured by surgery alone?"
d. "You need to talk about this with you oncologist and your
surgeon." Correct Answers B
A client receiving gentamycin intravenously reports that the
peripheral IV insertion site has become painful and reddened.
What is the priority nursing actions?
a. Contact the primary health care provider
b. Document findings in the electronic health record
c. Change the IV site to a new location
d. Stop the infusion of the drug. Correct Answers D
A client who has been taking the four first-line drugs for
tuberculosis treatment for a month reports all of the following
changes. Which changes would cause the nurse to collaborate
quickly with the health care provider? Select all that apply.
a. Blurry vision
b. Constipation
c. Difficulty sleeping
d. Nausea when drinking beer
e. Red-tinged urine
f. Sunburn with minimal sun exposure
g. Yellowing of the sclera Correct Answers A, G
A client who underwent radical neck surgery for head and neck
cancer 5 days ago tells the nurse that he is worried because his
, right shoulder is lower than the left and does not go back into
place when he tries to raise it. What is the nurse's best response?
a. "I will notify the surgeon right away because some leftover
tumor must be pressing on the nerve."
b. "The nerve to the shoulder was removed during surgery.
Physical therapy will help you to use other muscles to regain
some motion."
c. "This problem is not related to your surgery. If it persists after
you go home you will need to see your primary health care
provider about it."
d. "Your time under anesthesia was long and you are not yet
fully recovered. It is likely you will regain full motion in that
shoulder by the end of the week." Correct Answers B
A client with COPD has all the following ABG changes from
earlier today. Which change alerts the nurse to take immediate
action to prevent harm?
a. pH from 7.21 to 7.20
b. HCO3- remains the same at 31 mEq/L
c. PaCO2 from 45 mm Hg to 68 mm Hg
d. PaO2 from 88 mm Hg to 86 mm Hg Correct Answers C
A client with COPD has just been reclassified for disease
severity from a GOLD 2 to a GOLD 3. Which client statement
about changes in management or life-style indicate to the nurse
that more teaching is needed to prevent harm?
a. "This year I will get the pneumonia vaccination in addition to
a flu shot."
b. "Now I will try to rest as mush as possible and avoid any
unnecessary exercise."
A client had a 20-gauge short peripheral catheter (SPC) inserted
for antibiotic administration 48 hours ago. Which nursing
intervention is appropriate?
a. Discontinue the SPC
b. Relocated the SPC for infection control.
c. Assess the SPC for redness, swelling, or pain.
d. Change the occlusive dressing covering the SPC. Correct
Answers C
A client has just come to the floor after undergoing inner
maxillary fixation for a mandibular fracture with wiring of the
jaws. As the nurse raises the head of the bed, the client starts to
vomit a large amount of liquid vomitus. What is the nurse's
priority action?
a. Administer the prescribed antiemetic by the intravenous or
rectal route.
b. Immediately notify the surgeon, the anesthesiologist, or the
rapid response team.
c. Cut the wires holding his jaws together, and carefully remove
them from the mouth.
d. Reposition the client to the side and suction the mouth with a
large-bore catheter. Correct Answers D
A client newly diagnosed with stage I nonsmall cell lung cancer
(NSCLC) who is getting ready for curative surgery ask the nurse
whether the oncologist might consider this new drug he has seen
on television, pembrolizumab, instead of surgery. What is the
nurse's best response?
,a. "This drug will only work on those lung cancers that have the
right target and your tumor does not have it."
b. "This drug is approved for use in clients whose lung cancer
has metastasized not for early-stage cancers."
c. "Why would you want to take a drug for months when you
may be cured by surgery alone?"
d. "You need to talk about this with you oncologist and your
surgeon." Correct Answers B
A client receiving gentamycin intravenously reports that the
peripheral IV insertion site has become painful and reddened.
What is the priority nursing actions?
a. Contact the primary health care provider
b. Document findings in the electronic health record
c. Change the IV site to a new location
d. Stop the infusion of the drug. Correct Answers D
A client who has been taking the four first-line drugs for
tuberculosis treatment for a month reports all of the following
changes. Which changes would cause the nurse to collaborate
quickly with the health care provider? Select all that apply.
a. Blurry vision
b. Constipation
c. Difficulty sleeping
d. Nausea when drinking beer
e. Red-tinged urine
f. Sunburn with minimal sun exposure
g. Yellowing of the sclera Correct Answers A, G
A client who underwent radical neck surgery for head and neck
cancer 5 days ago tells the nurse that he is worried because his
, right shoulder is lower than the left and does not go back into
place when he tries to raise it. What is the nurse's best response?
a. "I will notify the surgeon right away because some leftover
tumor must be pressing on the nerve."
b. "The nerve to the shoulder was removed during surgery.
Physical therapy will help you to use other muscles to regain
some motion."
c. "This problem is not related to your surgery. If it persists after
you go home you will need to see your primary health care
provider about it."
d. "Your time under anesthesia was long and you are not yet
fully recovered. It is likely you will regain full motion in that
shoulder by the end of the week." Correct Answers B
A client with COPD has all the following ABG changes from
earlier today. Which change alerts the nurse to take immediate
action to prevent harm?
a. pH from 7.21 to 7.20
b. HCO3- remains the same at 31 mEq/L
c. PaCO2 from 45 mm Hg to 68 mm Hg
d. PaO2 from 88 mm Hg to 86 mm Hg Correct Answers C
A client with COPD has just been reclassified for disease
severity from a GOLD 2 to a GOLD 3. Which client statement
about changes in management or life-style indicate to the nurse
that more teaching is needed to prevent harm?
a. "This year I will get the pneumonia vaccination in addition to
a flu shot."
b. "Now I will try to rest as mush as possible and avoid any
unnecessary exercise."
