NURS ADULT HEALTH REVIEW QUESTIONS WITH COMPLETE
SOLUTION PACK 2023 GRADED A+
Pt arrives from PACU. Arousable and oriented but drifts off to sleep. VSS w/ RR =14. Which is
most appropriate nursing response?
A. Continue w/ heat to toe assessment
B. Call MD and ask PCA should be discontinued
C. Continue to stimulate the patient to keep him awake.
D. Encourage patient to drink some liquids.
RN removes urinary catheter. 12 hrs later voids 50 mL. Performs bladder scan that shows 400 mL of
urine. Calls MD, what is an expected following order?
A. Administer 500cc NS over 30
minutes B. Intermittent urinary
catheterization
C. Send urine culture
D. Administer furosemide 20 mg IVP
Ans: B. Intermittent urinary catheterization. That is standard of care not reinserting the Foley. Post void residue
>100mL is abnormal, if no urine in bladder scan=dehydration therefore give fluid bolus (500cc NS over 30min). Lasix
given to improve urine output.
Patient receiving morphine sulfate IV complains of feeling “itchy.” No rash on exam. Which of the
following meds would be most helpful?
A. Ondansteron 4 mg IV
B. Heparin 5000 units SQ
C. Benadryl 50 mg PO
D. Docusate Sodium 100 mg PO
Ans: C. Benadryl for complaints of itchiness but no rash with opioid/narcotic medications.
, NURS ADULT HEALTH REVIEW QUESTIONS WITH COMPLETE
SOLUTION PACK 2023 GRADED A+
Patient POD1 lumbar fusion. 6AM hemovac drained for 500 mL. At 8AM drained for 250 mL. What is
RN’s best response?
A. Continue to monitor drainage Qhr
B. Do nothing, this is expected
C. VS and call MD to report findings
D. Enter order to check Hgb and Hct
Ans: C. For most drains, should not have to empty more than 4 hours, no actual threshold for each type of
draining apparatus, most likely cause = bleeding need to consider this → chest tubes it is 100 mL per hour for
threshold, but want much less.
POD2 for anterior-posterior lumbar fusion. On morning assessmentRN finds pt has no N but abd is
distended with hypoactive bowel sounds and no flatus. RN should:
A. Call MD and ask about NG tube
placement B. Keep pt NPO and encourage
ambulation
C. Check medication record for stool softener
D. Encourage patient to take oral fluids to stimulate peristalsis
Which of following is unexpected order POD1 following anterior posterior lumbar
fusion? A. Ibuprofen 800 mg PO
B. PCA dilaudid .12 Q6min with 1.2 mg Qhr
C. Foley catheter to monitor u/o
D. TLSO brace for ambulation
Pt hx of spondylolisthesis in lumbar spine admitted for pain control. Which finding is most cause
for concerning?
A. Pain 8 out of 10
B. Numbness in buttocks and thighs
, NURS ADULT HEALTH REVIEW QUESTIONS WITH COMPLETE
SOLUTION PACK 2023 GRADED A+
C. Complaint of dysuria
D. Episode of urinary incontinence1
SOLUTION PACK 2023 GRADED A+
Pt arrives from PACU. Arousable and oriented but drifts off to sleep. VSS w/ RR =14. Which is
most appropriate nursing response?
A. Continue w/ heat to toe assessment
B. Call MD and ask PCA should be discontinued
C. Continue to stimulate the patient to keep him awake.
D. Encourage patient to drink some liquids.
RN removes urinary catheter. 12 hrs later voids 50 mL. Performs bladder scan that shows 400 mL of
urine. Calls MD, what is an expected following order?
A. Administer 500cc NS over 30
minutes B. Intermittent urinary
catheterization
C. Send urine culture
D. Administer furosemide 20 mg IVP
Ans: B. Intermittent urinary catheterization. That is standard of care not reinserting the Foley. Post void residue
>100mL is abnormal, if no urine in bladder scan=dehydration therefore give fluid bolus (500cc NS over 30min). Lasix
given to improve urine output.
Patient receiving morphine sulfate IV complains of feeling “itchy.” No rash on exam. Which of the
following meds would be most helpful?
A. Ondansteron 4 mg IV
B. Heparin 5000 units SQ
C. Benadryl 50 mg PO
D. Docusate Sodium 100 mg PO
Ans: C. Benadryl for complaints of itchiness but no rash with opioid/narcotic medications.
, NURS ADULT HEALTH REVIEW QUESTIONS WITH COMPLETE
SOLUTION PACK 2023 GRADED A+
Patient POD1 lumbar fusion. 6AM hemovac drained for 500 mL. At 8AM drained for 250 mL. What is
RN’s best response?
A. Continue to monitor drainage Qhr
B. Do nothing, this is expected
C. VS and call MD to report findings
D. Enter order to check Hgb and Hct
Ans: C. For most drains, should not have to empty more than 4 hours, no actual threshold for each type of
draining apparatus, most likely cause = bleeding need to consider this → chest tubes it is 100 mL per hour for
threshold, but want much less.
POD2 for anterior-posterior lumbar fusion. On morning assessmentRN finds pt has no N but abd is
distended with hypoactive bowel sounds and no flatus. RN should:
A. Call MD and ask about NG tube
placement B. Keep pt NPO and encourage
ambulation
C. Check medication record for stool softener
D. Encourage patient to take oral fluids to stimulate peristalsis
Which of following is unexpected order POD1 following anterior posterior lumbar
fusion? A. Ibuprofen 800 mg PO
B. PCA dilaudid .12 Q6min with 1.2 mg Qhr
C. Foley catheter to monitor u/o
D. TLSO brace for ambulation
Pt hx of spondylolisthesis in lumbar spine admitted for pain control. Which finding is most cause
for concerning?
A. Pain 8 out of 10
B. Numbness in buttocks and thighs
, NURS ADULT HEALTH REVIEW QUESTIONS WITH COMPLETE
SOLUTION PACK 2023 GRADED A+
C. Complaint of dysuria
D. Episode of urinary incontinence1
