Adult Health III Final Exam
1. The nurse is caring for a patient who has septic shock. Which
assessment finding is most important for the nurse to report to the health
care provider?
a. skin cool and clammy
b. heart rate of 118 beats/min
c. blood pressure of 92/56
d. O2 saturation of 93% on room air: Answer: a
2. Which assessment finding by the nurse caring for a patient
receiving mechanical ventilation indicates the need for suctioning?
a. the patient's respiratory rate is 32 breaths/min
b. the patient has occasional audible expiratory wheezes
c. the patient's oxygen saturation drops to 93%
,d. the patient was last suctioned 6 hours ago: Answer: a
3. The nurse in the emergency department is caring for a client with a
history of smoking who is obese and admitted with epigastric pain. The
client is diagnosed with abdominal aortic aneurysm after having an X-ray.
During assessment the nurse notes ecchymosis to the client's back side.
Which of the following actions would be priority for the nurse to take?
a. prepare the client for a blood transfusion
b. obtain informed consent for emergency surgery
c. obtain the client's blood pressure
d. assess the client's lung sounds: Answer: b
4. The nurse is caring for a client who is experiencing neurogenic shock
after a spinal cord injury. The nurse has taught the client's spouse about
neurogenic shock. Which of the following statements by the client's
spouse requires follow-up?
a. this type of shock causes excessive urine loss
b. my spouse may have difficulty maintaining normal body temperature
c. this type of shock causes the heart rate to be too low
,d. my spouse is receiving medicine to keep the blood pressure high
enough-
: Answer: a
5. The nurse is caring for a client who was exposed to inhalation anthrax
and is to receive prescribed ciprofloxacin 800mg, once per day, IV for 60
days. The nurse has 800mg/250mL in D5W to be infused over 2 hours. How
many mL per hour should the nurse administer? Do not round your
answer. Enter numeric value only.: Answer: 125
6. A nurse is caring for a client experiencing atrial flutter in the
telemetry monitor. Which of the following characteristics and
manifestations should
, the nurse expect to see? Select all that apply.
a. shortened PR interval
b. Hypertension
c. an irregular atrial rate that is between 350 and 600 beats/min
d. Normal QRS complex
e. Alcohol intoxication
f. a regular ventricular rate that is greater than or less than 100 beats/min: -
Answer: a, c, f
7. The nurse is assessing a client with a head injury who is exhibiting
an altered level of consciousness (LOC) and had clear fluid leaking from
the right ear. Which of the following actions would be priority for the
nurse to take?
a. prepare the client for surgery
b. monitor the client for increased intercranial pressure (ICP)
c. insert a peripheral intravenous catheter
d. provide seizure precautions: Answer: b
8. Which patient is most appropriate for the burn unit charge nurse to
assign to a registered nurse (RN) who has floated from the hospital
medical unit?
1. The nurse is caring for a patient who has septic shock. Which
assessment finding is most important for the nurse to report to the health
care provider?
a. skin cool and clammy
b. heart rate of 118 beats/min
c. blood pressure of 92/56
d. O2 saturation of 93% on room air: Answer: a
2. Which assessment finding by the nurse caring for a patient
receiving mechanical ventilation indicates the need for suctioning?
a. the patient's respiratory rate is 32 breaths/min
b. the patient has occasional audible expiratory wheezes
c. the patient's oxygen saturation drops to 93%
,d. the patient was last suctioned 6 hours ago: Answer: a
3. The nurse in the emergency department is caring for a client with a
history of smoking who is obese and admitted with epigastric pain. The
client is diagnosed with abdominal aortic aneurysm after having an X-ray.
During assessment the nurse notes ecchymosis to the client's back side.
Which of the following actions would be priority for the nurse to take?
a. prepare the client for a blood transfusion
b. obtain informed consent for emergency surgery
c. obtain the client's blood pressure
d. assess the client's lung sounds: Answer: b
4. The nurse is caring for a client who is experiencing neurogenic shock
after a spinal cord injury. The nurse has taught the client's spouse about
neurogenic shock. Which of the following statements by the client's
spouse requires follow-up?
a. this type of shock causes excessive urine loss
b. my spouse may have difficulty maintaining normal body temperature
c. this type of shock causes the heart rate to be too low
,d. my spouse is receiving medicine to keep the blood pressure high
enough-
: Answer: a
5. The nurse is caring for a client who was exposed to inhalation anthrax
and is to receive prescribed ciprofloxacin 800mg, once per day, IV for 60
days. The nurse has 800mg/250mL in D5W to be infused over 2 hours. How
many mL per hour should the nurse administer? Do not round your
answer. Enter numeric value only.: Answer: 125
6. A nurse is caring for a client experiencing atrial flutter in the
telemetry monitor. Which of the following characteristics and
manifestations should
, the nurse expect to see? Select all that apply.
a. shortened PR interval
b. Hypertension
c. an irregular atrial rate that is between 350 and 600 beats/min
d. Normal QRS complex
e. Alcohol intoxication
f. a regular ventricular rate that is greater than or less than 100 beats/min: -
Answer: a, c, f
7. The nurse is assessing a client with a head injury who is exhibiting
an altered level of consciousness (LOC) and had clear fluid leaking from
the right ear. Which of the following actions would be priority for the
nurse to take?
a. prepare the client for surgery
b. monitor the client for increased intercranial pressure (ICP)
c. insert a peripheral intravenous catheter
d. provide seizure precautions: Answer: b
8. Which patient is most appropriate for the burn unit charge nurse to
assign to a registered nurse (RN) who has floated from the hospital
medical unit?
