3
Adult Health Form A
1. A nurse is preparing to administer thrombolytic therapy to a client who had an
ischemic stroke. Which of the following is an appropriate nursing action?
a. Start the therapy within 8 hr
b. Insert an indwelling urinary catheter after therapy begins
c. Monitor blood pressure every 30 min during the infusion
d. Elevate the head of bed between 25 and 30
2. A nurse is teaching a client about the use of an incentive spirometer. Which of the
following instructions should the nurse include in the teaching?
a. Place hands on the upper abdomen during inhalation
b. Exhale slowly through pursed lips
c. Hold breaths about 3 to 5 seconds before exhaling
d. Position the mouthpiece 2.5 cm (1 in) from the mouth
3. A nurse is assessing a client who is 12 hr postoperative following a colon resection. Which
of the following findings should the nurse report to the surgeon?
a. Heart rate 90/min
b. Hgb 8.2 g/dL
c. Gastric pH of 3.0
d. Absent bowel sounds
4. A nurse is caring for a client who has diabetes insipidus. Which of the following
medications should the nurse plan to administer?
a. Regular insulin
b. Furosemide
c. Desmopressin
d. Lithium carbonate
5. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several
times daily for 3 years. Which of the following tests should the nurse monitor?
a. Stool for occult blood
b. Urine for white blood cells
c. Fasting blood glucose
d. Serum calcium
, 3
6. A nurse in the emergency department is assessing a client. Which of the following actions
should the nurse take first? (Click on the “Exhibit” button for additional information about
the client. There are three tabs that contain separate categories of data.)
a. Obtain a sputum sample for culture
b. Prepare the client for a chest x-ray
c. Initiate airborne precautions
d. Administer ondansetron
7. A nurse is contacting the provider of a client who has cancer and is experiencing
breakthrough pain. Which of the following prescriptions should the nurse
anticipate?
a. Intravenous dexamethasone
b. Transmucosal fentanyl
c. Oral acetaminophen
d. Intramuscular meperidine
8. A nurse is admitting a client who reports chest pain and has been placed on a telemetry
monitor. Which of the following should the nurse analyze to determine whether the client
is experiencing a myocardial infarction?
a. QRS duration
b. ST segment
c. T wave
d. PR interval
9. A nurse is teaching a client who has ovarian cancer about skin care following
radiation treatment. Which of the following instructions should the nurse include?
a. Apply over-the-counter moisturizer to the radiation site
b. Cover the radiation site loosely with a gauze wrap before dressing
c. Use a soft washcloth to clean the area around the radiation site
d. Pat the skin on the radiation site to dry it
10. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that
the client has bounding peripheral pulses, hypertension, and distended jugular veins. The
nurse should anticipate administering which of the following prescribed medications?
a. Acetaminophen
b. Furosemide
c. Diphenhydramine
d. Pantoprazole
, 3
11. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of
hypomagnesemia. Which of the following findings indicates effectiveness of the
medication?
a. Lungs clear
b. Hyperactive bowel sounds
c. Blood pressure 90/50 mm Hg
d. Apical pulse 82/min
12. A nurse is preparing a client for a lumbar puncture. Which of the following images
indicates the position the nurse should assist the client into for this procedure?
Answer is exhibit “C” – picture shows pt lying in side-lying left position
13. A nurse is reviewing a client’s ABG results: pH 7.42, PaCO2 30 mm Hg, and HCO3- 21
mEq/L. The nurse should recognize these findings as an indication of which of the following
conditions?
a. Compensated respiratory alkalosis
b. Uncompensated respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis
14. A nurse is preparing to administer daily medications to a client who is undergoing a
procedure at 1000 that requires IV contrast dye. Which of the following routine medications
to give at 0800 should the nurse withhold?
a. Metoprolol
b. Metformin
c. Fluticasone
d. Valproic acid
15. A nurse is planning care for a client who is experiencing seizures secondary to
meningitis. Which of the following interventions should the nurse include in the plan of
care? (Select all that apply.)
a. Assist the client to ambulate every 4 hr
b. Place a tongue blade at the bedside
c. Have suction equipment at the bedside
d. Dim the overhead lights
e. Apply a warming blanket
16. A nurse is caring for a client who has a pressure ulcer with necrotic tissue and requires
wet- to-damp dressing changes daily. Which of the following types of debridement should the
nurse include in the plan of care?
Adult Health Form A
1. A nurse is preparing to administer thrombolytic therapy to a client who had an
ischemic stroke. Which of the following is an appropriate nursing action?
a. Start the therapy within 8 hr
b. Insert an indwelling urinary catheter after therapy begins
c. Monitor blood pressure every 30 min during the infusion
d. Elevate the head of bed between 25 and 30
2. A nurse is teaching a client about the use of an incentive spirometer. Which of the
following instructions should the nurse include in the teaching?
a. Place hands on the upper abdomen during inhalation
b. Exhale slowly through pursed lips
c. Hold breaths about 3 to 5 seconds before exhaling
d. Position the mouthpiece 2.5 cm (1 in) from the mouth
3. A nurse is assessing a client who is 12 hr postoperative following a colon resection. Which
of the following findings should the nurse report to the surgeon?
a. Heart rate 90/min
b. Hgb 8.2 g/dL
c. Gastric pH of 3.0
d. Absent bowel sounds
4. A nurse is caring for a client who has diabetes insipidus. Which of the following
medications should the nurse plan to administer?
a. Regular insulin
b. Furosemide
c. Desmopressin
d. Lithium carbonate
5. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several
times daily for 3 years. Which of the following tests should the nurse monitor?
a. Stool for occult blood
b. Urine for white blood cells
c. Fasting blood glucose
d. Serum calcium
, 3
6. A nurse in the emergency department is assessing a client. Which of the following actions
should the nurse take first? (Click on the “Exhibit” button for additional information about
the client. There are three tabs that contain separate categories of data.)
a. Obtain a sputum sample for culture
b. Prepare the client for a chest x-ray
c. Initiate airborne precautions
d. Administer ondansetron
7. A nurse is contacting the provider of a client who has cancer and is experiencing
breakthrough pain. Which of the following prescriptions should the nurse
anticipate?
a. Intravenous dexamethasone
b. Transmucosal fentanyl
c. Oral acetaminophen
d. Intramuscular meperidine
8. A nurse is admitting a client who reports chest pain and has been placed on a telemetry
monitor. Which of the following should the nurse analyze to determine whether the client
is experiencing a myocardial infarction?
a. QRS duration
b. ST segment
c. T wave
d. PR interval
9. A nurse is teaching a client who has ovarian cancer about skin care following
radiation treatment. Which of the following instructions should the nurse include?
a. Apply over-the-counter moisturizer to the radiation site
b. Cover the radiation site loosely with a gauze wrap before dressing
c. Use a soft washcloth to clean the area around the radiation site
d. Pat the skin on the radiation site to dry it
10. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that
the client has bounding peripheral pulses, hypertension, and distended jugular veins. The
nurse should anticipate administering which of the following prescribed medications?
a. Acetaminophen
b. Furosemide
c. Diphenhydramine
d. Pantoprazole
, 3
11. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of
hypomagnesemia. Which of the following findings indicates effectiveness of the
medication?
a. Lungs clear
b. Hyperactive bowel sounds
c. Blood pressure 90/50 mm Hg
d. Apical pulse 82/min
12. A nurse is preparing a client for a lumbar puncture. Which of the following images
indicates the position the nurse should assist the client into for this procedure?
Answer is exhibit “C” – picture shows pt lying in side-lying left position
13. A nurse is reviewing a client’s ABG results: pH 7.42, PaCO2 30 mm Hg, and HCO3- 21
mEq/L. The nurse should recognize these findings as an indication of which of the following
conditions?
a. Compensated respiratory alkalosis
b. Uncompensated respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis
14. A nurse is preparing to administer daily medications to a client who is undergoing a
procedure at 1000 that requires IV contrast dye. Which of the following routine medications
to give at 0800 should the nurse withhold?
a. Metoprolol
b. Metformin
c. Fluticasone
d. Valproic acid
15. A nurse is planning care for a client who is experiencing seizures secondary to
meningitis. Which of the following interventions should the nurse include in the plan of
care? (Select all that apply.)
a. Assist the client to ambulate every 4 hr
b. Place a tongue blade at the bedside
c. Have suction equipment at the bedside
d. Dim the overhead lights
e. Apply a warming blanket
16. A nurse is caring for a client who has a pressure ulcer with necrotic tissue and requires
wet- to-damp dressing changes daily. Which of the following types of debridement should the
nurse include in the plan of care?
