Adult 1 Test 5 Questions With Complete Solutions
A 55-yr-old patient with increasing dyspnea is being evaluated
for a possible diagnosis of
chronic obstructive pulmonary disease (COPD). When teaching
a patient about pulmonary
spirometry for this condition, what is the most important
question the nurse should ask?
a. "Are you claustrophobic?"
b. "Are you allergic to shellfish?"
c. "Have you taken any bronchodilators today?"
d. "Do you have any metal implants or prostheses?" Correct
Answers C
A diabetic patient's arterial blood gas (ABG) results are pH 7.28;
PaCO2 34 mm Hg; PaO2 85
mm Hg; HCO3
-
18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions c. Low oxygen saturation (SpO2)
b. Kussmaul respirations d. Decreased venous O2 pressure
Correct Answers B
A lobectomy is scheduled for a patient with stage I non-small
cell lung cancer. The patient
tells the nurse, "I would rather have chemotherapy than
surgery." Which response by the
nurse is most appropriate?
a. "Are you afraid that the surgery will be very painful?"
b. "Did you have bad experiences with previous surgeries?"
c. "Tell me what you know about the treatments available."
,d. "Surgery is the treatment of choice for stage I lung cancer."
Correct Answers C
A new nurse performs a dressing change on a stage II left heel
pressure ulcer. Which action by
the new nurse indicates a need for further teaching about
pressure ulcer care?
a. The new nurse cleans the ulcer with half-strength peroxide.
b. The new nurse uses a hydrocolloid dressing (DuoDerm)on the
ulcer.
c. The new nurse irrigates the pressure ulcer with saline using a
30-mL syringe.
d. The new nurse inserts a sterile cotton-tipped applicator into
the pressure ulcer. Correct Answers A
A nurse is assessing a newly admitted patient with chronic heart
failure who forgot to take
prescribed medications and seems confused. The patient has
peripheral edema and shortness
of breath. Which assessment should the nurse complete first?
a. Skin turgor c. Mental status
b. Heart sounds d. Capillary refill Correct Answers C
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 the incision for bleeding.
b. Maintain adequate IV fluid intake.
c. Keep the patient in semi-Fowler's position.
,d. Teach the patient to suction the tracheostomy. Correct
Answers C
A nurse obtains a health history from a patient who has a 35
pack-year smoking history. The
patient complains of hoarseness and tightness in the throat and
difficulty swallowing. Which
question is important for the nurse to ask?
a. "How much alcohol do you drink in an average week?"
b. "Do you have a family history of head or neck cancer?"
c. "Have you had frequent streptococcal throat infections?"
d. "Do you use antihistamines for upper airway congestion?"
Correct Answers A
A patient admitted to the emergency department complaining of
sudden onset shortness of
breath is diagnosed with a possible pulmonary embolus. How
should the nurse prepare the
patient for diagnostic testing to confirm the diagnosis?
a. Ensure that the patient has been NPO.
b. Start an IV so contrast media may be given.
c. Inform radiology that radioactive glucose preparation is
needed.
d. Instruct the patient to expect to inspire deeply and exhale
forcefully. Correct Answers B
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
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
A patient comes to the clinic complaining of frequent, watery
stools for the past 2 days.
Which action should the nurse take first?
a. Obtain the baseline weight.
b. Check the patient's blood pressure.
c. Draw blood for serum electrolyte levels.
d. Ask about extremity numbness or tingling. Correct Answers
B
A patient diagnosed with active tuberculosis (TB) is homeless
and has a history of alcohol
abuse. Which intervention by the nurse will be most effective in
ensuring adherence with the
treatment regimen?
a. Repeat warnings about the high risk for infecting others
several times.
A 55-yr-old patient with increasing dyspnea is being evaluated
for a possible diagnosis of
chronic obstructive pulmonary disease (COPD). When teaching
a patient about pulmonary
spirometry for this condition, what is the most important
question the nurse should ask?
a. "Are you claustrophobic?"
b. "Are you allergic to shellfish?"
c. "Have you taken any bronchodilators today?"
d. "Do you have any metal implants or prostheses?" Correct
Answers C
A diabetic patient's arterial blood gas (ABG) results are pH 7.28;
PaCO2 34 mm Hg; PaO2 85
mm Hg; HCO3
-
18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions c. Low oxygen saturation (SpO2)
b. Kussmaul respirations d. Decreased venous O2 pressure
Correct Answers B
A lobectomy is scheduled for a patient with stage I non-small
cell lung cancer. The patient
tells the nurse, "I would rather have chemotherapy than
surgery." Which response by the
nurse is most appropriate?
a. "Are you afraid that the surgery will be very painful?"
b. "Did you have bad experiences with previous surgeries?"
c. "Tell me what you know about the treatments available."
,d. "Surgery is the treatment of choice for stage I lung cancer."
Correct Answers C
A new nurse performs a dressing change on a stage II left heel
pressure ulcer. Which action by
the new nurse indicates a need for further teaching about
pressure ulcer care?
a. The new nurse cleans the ulcer with half-strength peroxide.
b. The new nurse uses a hydrocolloid dressing (DuoDerm)on the
ulcer.
c. The new nurse irrigates the pressure ulcer with saline using a
30-mL syringe.
d. The new nurse inserts a sterile cotton-tipped applicator into
the pressure ulcer. Correct Answers A
A nurse is assessing a newly admitted patient with chronic heart
failure who forgot to take
prescribed medications and seems confused. The patient has
peripheral edema and shortness
of breath. Which assessment should the nurse complete first?
a. Skin turgor c. Mental status
b. Heart sounds d. Capillary refill Correct Answers C
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 the incision for bleeding.
b. Maintain adequate IV fluid intake.
c. Keep the patient in semi-Fowler's position.
,d. Teach the patient to suction the tracheostomy. Correct
Answers C
A nurse obtains a health history from a patient who has a 35
pack-year smoking history. The
patient complains of hoarseness and tightness in the throat and
difficulty swallowing. Which
question is important for the nurse to ask?
a. "How much alcohol do you drink in an average week?"
b. "Do you have a family history of head or neck cancer?"
c. "Have you had frequent streptococcal throat infections?"
d. "Do you use antihistamines for upper airway congestion?"
Correct Answers A
A patient admitted to the emergency department complaining of
sudden onset shortness of
breath is diagnosed with a possible pulmonary embolus. How
should the nurse prepare the
patient for diagnostic testing to confirm the diagnosis?
a. Ensure that the patient has been NPO.
b. Start an IV so contrast media may be given.
c. Inform radiology that radioactive glucose preparation is
needed.
d. Instruct the patient to expect to inspire deeply and exhale
forcefully. Correct Answers B
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
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
A patient comes to the clinic complaining of frequent, watery
stools for the past 2 days.
Which action should the nurse take first?
a. Obtain the baseline weight.
b. Check the patient's blood pressure.
c. Draw blood for serum electrolyte levels.
d. Ask about extremity numbness or tingling. Correct Answers
B
A patient diagnosed with active tuberculosis (TB) is homeless
and has a history of alcohol
abuse. Which intervention by the nurse will be most effective in
ensuring adherence with the
treatment regimen?
a. Repeat warnings about the high risk for infecting others
several times.
