Nursing of Adults 1 Final Exam Questions With Complete
Solutions
A 73-year-old patient with chronic atrial fibrillation develops
sudden severe pain, pulselessness, pallor, and coolness in the
right leg. The nurse should notify the health care provider and
immediately Correct Answers Keep the patient in bed in the
supine position
A chemotherapy drug that causes alopecia is prescribed for a
patient. Which action should the nurse take to maintain the
patient's self-esteem?
a. Tell the patient to limit social contacts until regrowth of the
hair occurs.
b. Encourage the patient to purchase a wig or hat and wear it
once hair loss begins.
c. Teach the patient to gently wash hair with a mild shampoo to
minimize hair loss.
d. Inform the patient that hair usually grows back once the
chemotherapy is complete. Correct Answers b. Encourage the
patient to purchase a wig or hat and wear it once hair loss
begins.
A critical action by the nurse caring for a patient with an acute
exacerbation of polycythemia vera is to
a. place the patient on bed rest.
b. administer iron supplements.
c. avoid use of aspirin products.
d. monitor fluid intake and output. Correct Answers d. monitor
fluid intake and output.
,A newly admitted patient is diagnosed with hyponatremia.
When making room assignments, the charge nurse should take
which action?
a. Assign the patient to a room near the nurse's station.
b. Place the patient in a room nearest to the water fountain.
c. Place the patient on telemetry to monitor for peaked T waves.
d. Assign the patient to a semi-private room and place an order
for a low-salt diet. Correct Answers a. Assign the patient to a
room near the nurse's station.
A nurse assesses a postoperative patient 2 days after chest
surgery. What findings indicate that the patient requires better
pain management (select all that apply)?
a.Confusion
b.Shallow breathing
c.Hypoglycemia
d.Elevated temperature
e.Poor cough effort Correct Answers a.Confusion
b.Shallow breathing
d.Elevated temperature
e.Poor cough effort
A nurse is caring for a patient who has had a total laryngectomy
and radical neck dissection. During the first 24 hours after
surgery what is the priority nursing action?
a.Monitor for bleeding.
b.Maintain adequate IV fluid intake.
c.Suction tracheostomy every eight hours.
d.Keep the patient in semi-Fowler's position. Correct Answers
d.Keep the patient in semi-Fowler's position.
,A nurse reviews the laboratory data for an older patient. The
nurse would be most concerned about which finding?
a. Hematocrit of 35%
b. Hemoglobin of 11.8 g/dL
c. Platelet count of 400,000/µL
d. White blood cell (WBC) count of 2800/µL Correct Answers
d. White blood cell (WBC) count of 2800/µL
A nurse who is caring for patient with a tracheostomy tube in
place has just auscultated rhonchi bilaterally. If the patient is
unsuccessful in coughing up secretions, what action should the
nurse take?
a.Encourage increased incentive spirometer use.
b.Encourage the patient to increase oral fluid intake.
c.Put on sterile gloves and use a sterile catheter to suction.
d. Preoxygenate the patient for 3 minutes before suctioning.
Correct Answers c.Put on sterile gloves and use a sterile
catheter to suction.
A patient admitted to the coronary care unit (CCU) with an ST-
segment-elevation myocardial infarction (STEMI) is restless and
anxious. The blood pressure is 86/40 mm Hg, and heart rate is
132 beats/min. Based on this information, which patient problem
is the priority?
a. Anxiety
b. Acute pain
c. Stress management
d. Decreased cardiac output Correct Answers d. Decreased
cardiac output
, A patient arrives in the ear, nose, and throat clinic complaining
of a piece of tissue being "stuck up my nose" and with foul-
smelling nasal drainage from the right nare. Which action should
the nurse take first?
a.Notify the clinic health care provider.
b.Obtain aerobic culture specimens of the drainage.
c.Ask the patient about how the cotton got into the nose.
d.Have the patient occlude the left nare and blow the nose.
Correct Answers d.Have the patient occlude the left nare and
blow the nose.
A patient arrives in the emergency department with a swollen
ankle after a soccer injury. Which action by the nurse is
appropriate?
a. Elevate the ankle above heart level. b. Apply a warm moist
pack to the ankle.
c. Ask the patient to try bearing weight on the ankle.
d. Assess the ankle's passive range of motion (ROM). Correct
Answers a. Elevate the ankle above heart level.
A patient arrives in the emergency department with facial and
chest burns caused by a house fire. Which action should the
nurse take first?
a. Auscultate the patient's lung sounds.
b. Determine the extent and depth of the burns.
c. Infuse the ordered lactated Ringer's solution.
d. Administer the ordered hydromorphone (Dilaudid). Correct
Answers a. Auscultate the patient's lung sounds.
Solutions
A 73-year-old patient with chronic atrial fibrillation develops
sudden severe pain, pulselessness, pallor, and coolness in the
right leg. The nurse should notify the health care provider and
immediately Correct Answers Keep the patient in bed in the
supine position
A chemotherapy drug that causes alopecia is prescribed for a
patient. Which action should the nurse take to maintain the
patient's self-esteem?
a. Tell the patient to limit social contacts until regrowth of the
hair occurs.
b. Encourage the patient to purchase a wig or hat and wear it
once hair loss begins.
c. Teach the patient to gently wash hair with a mild shampoo to
minimize hair loss.
d. Inform the patient that hair usually grows back once the
chemotherapy is complete. Correct Answers b. Encourage the
patient to purchase a wig or hat and wear it once hair loss
begins.
A critical action by the nurse caring for a patient with an acute
exacerbation of polycythemia vera is to
a. place the patient on bed rest.
b. administer iron supplements.
c. avoid use of aspirin products.
d. monitor fluid intake and output. Correct Answers d. monitor
fluid intake and output.
,A newly admitted patient is diagnosed with hyponatremia.
When making room assignments, the charge nurse should take
which action?
a. Assign the patient to a room near the nurse's station.
b. Place the patient in a room nearest to the water fountain.
c. Place the patient on telemetry to monitor for peaked T waves.
d. Assign the patient to a semi-private room and place an order
for a low-salt diet. Correct Answers a. Assign the patient to a
room near the nurse's station.
A nurse assesses a postoperative patient 2 days after chest
surgery. What findings indicate that the patient requires better
pain management (select all that apply)?
a.Confusion
b.Shallow breathing
c.Hypoglycemia
d.Elevated temperature
e.Poor cough effort Correct Answers a.Confusion
b.Shallow breathing
d.Elevated temperature
e.Poor cough effort
A nurse is caring for a patient who has had a total laryngectomy
and radical neck dissection. During the first 24 hours after
surgery what is the priority nursing action?
a.Monitor for bleeding.
b.Maintain adequate IV fluid intake.
c.Suction tracheostomy every eight hours.
d.Keep the patient in semi-Fowler's position. Correct Answers
d.Keep the patient in semi-Fowler's position.
,A nurse reviews the laboratory data for an older patient. The
nurse would be most concerned about which finding?
a. Hematocrit of 35%
b. Hemoglobin of 11.8 g/dL
c. Platelet count of 400,000/µL
d. White blood cell (WBC) count of 2800/µL Correct Answers
d. White blood cell (WBC) count of 2800/µL
A nurse who is caring for patient with a tracheostomy tube in
place has just auscultated rhonchi bilaterally. If the patient is
unsuccessful in coughing up secretions, what action should the
nurse take?
a.Encourage increased incentive spirometer use.
b.Encourage the patient to increase oral fluid intake.
c.Put on sterile gloves and use a sterile catheter to suction.
d. Preoxygenate the patient for 3 minutes before suctioning.
Correct Answers c.Put on sterile gloves and use a sterile
catheter to suction.
A patient admitted to the coronary care unit (CCU) with an ST-
segment-elevation myocardial infarction (STEMI) is restless and
anxious. The blood pressure is 86/40 mm Hg, and heart rate is
132 beats/min. Based on this information, which patient problem
is the priority?
a. Anxiety
b. Acute pain
c. Stress management
d. Decreased cardiac output Correct Answers d. Decreased
cardiac output
, A patient arrives in the ear, nose, and throat clinic complaining
of a piece of tissue being "stuck up my nose" and with foul-
smelling nasal drainage from the right nare. Which action should
the nurse take first?
a.Notify the clinic health care provider.
b.Obtain aerobic culture specimens of the drainage.
c.Ask the patient about how the cotton got into the nose.
d.Have the patient occlude the left nare and blow the nose.
Correct Answers d.Have the patient occlude the left nare and
blow the nose.
A patient arrives in the emergency department with a swollen
ankle after a soccer injury. Which action by the nurse is
appropriate?
a. Elevate the ankle above heart level. b. Apply a warm moist
pack to the ankle.
c. Ask the patient to try bearing weight on the ankle.
d. Assess the ankle's passive range of motion (ROM). Correct
Answers a. Elevate the ankle above heart level.
A patient arrives in the emergency department with facial and
chest burns caused by a house fire. Which action should the
nurse take first?
a. Auscultate the patient's lung sounds.
b. Determine the extent and depth of the burns.
c. Infuse the ordered lactated Ringer's solution.
d. Administer the ordered hydromorphone (Dilaudid). Correct
Answers a. Auscultate the patient's lung sounds.
