Adult Health Nursing Integration Exam
1. The physician orders oropharyngeal suctioning as needed for a client in a coma. The nurse prepares to
suction when assessment reveals: *
a. Drainage of mucus and saliva from the mouth
b. The presence of gurgling sounds with each breath
c. Development of cyanosis in the nailbed of the fingers
d. The presence of a dry cough at increasingly frequent intervals
2. When assessing a client with varicose veins, the nurse should expect: *
a. Distorted toenails
b. Complaints of leg fatigue
c. Localized heat in the calves
d. Reddened areas on the legs
3. In response to a question about varicose veins, the nurse relates that they tend to develop as a result
of: *
a. Repeated venous inflammatory episodes
b. Increased hydrostatic pressure in the veins
c. Valve obstructing the flow of blood to the heart
d. Hereditary weakness in the surrounding leg muscles
4. Preoperative teaching for a client who is to have cataract surgery should include the importance of: *
a. Remaining flat for 3 hours
b. Breathing and coughing deeply
c. Eating a soft diet for 2 days
d. Avoiding bending from the waist
5. A client receiving hemodialysis has AV fistula for circulatory access. An important nursing
consideration in caring for this client is: *
,a. Preventing infection
b. Observing aseptic technique
c. Checking weight daily
d. Observing arm precaution
6. When a client develops a hemolytic transfusion reaction because of incompatible blood, the nurse
should assess the client for: *
a. Dyspnea
b. Backache
c. Cyanosis
d. Bradycardia
7. As a result of transfusion reaction, a client suffers kidney damage. When determining kidney damage,
the most significant clinical response that the nurse should assess is: *
a. Polyuria
b. Decreased urinary output
c. Hematuria
d. Acute pain over the kidney area
8. A client with acute renal failure complains of nausea, pain in the abdomen, diarrhea, and muscular
weakness. The nurse notes an irregularity in pulse and signs of pulmonary edema. These are probably
manifestations of: *
a. Calcium excess
b. Sodium deficiency
c. Potassium excess
d. Calcium deficiency
9. When caring for a client who is receiving peritoneal dialysis, the nurse should: *
a. Position the client from side to side if fluid is not draining properly
b. Notify the physician if there is a deficit of 200 ml in the drainage fluid
, c. Maintain the client in a flat, supine position during the entire procedure
d. Remove the cannula at the end of procedure and apply a dry, sterile dressing
10. The physician orders oxygen therapy via nasal cannula (nasal prongs) at two liters per minute for an
elderly client with heart failure. A priority nursing action would be to: *
a. Always maintain the client on bed rest
b. Investigate if the client has COPD
c. Determine if the client is a mouth breather
d. Obtain the oxygen saturation measurements
11. A client with a history of acute myocardial infarction complains about the lack of salt in the food. The
nurse should explain that the salt must be limited to: *
a. Prevent any rise in blood pressure from the tissue edema
b. Produce a diuretic effect and reduce the circulating blood volume
c. Reduce the amount of edema present, which interferes with the heart action
d. Prevent the further accumulation of fluid and increasing workload of the heart
12. A client has a diagnosis of acute cholecystitis with biliary colic. In addition to pain in the right upper
quadrant, the nurse should expect the client to have: *
a. Melena and diarrhea
b. Vomiting of coffee–ground emesis
c. An intolerance to foods high in lipids
d. Gnawing pain when the stomach is empty
13. Following a cholecystectomy, Mrs. Santillan should be assessed for signs of bleeding or hemorrhage.
These observations are made because: *
a. Prostaglandins are released at the surgical site
b. The inflammatory process interferes with platelet formation
c. Diaphragmatic excursion places pressure on the suture line
d. Blood clotting may be hindered by lack of vitamin K absorption
1. The physician orders oropharyngeal suctioning as needed for a client in a coma. The nurse prepares to
suction when assessment reveals: *
a. Drainage of mucus and saliva from the mouth
b. The presence of gurgling sounds with each breath
c. Development of cyanosis in the nailbed of the fingers
d. The presence of a dry cough at increasingly frequent intervals
2. When assessing a client with varicose veins, the nurse should expect: *
a. Distorted toenails
b. Complaints of leg fatigue
c. Localized heat in the calves
d. Reddened areas on the legs
3. In response to a question about varicose veins, the nurse relates that they tend to develop as a result
of: *
a. Repeated venous inflammatory episodes
b. Increased hydrostatic pressure in the veins
c. Valve obstructing the flow of blood to the heart
d. Hereditary weakness in the surrounding leg muscles
4. Preoperative teaching for a client who is to have cataract surgery should include the importance of: *
a. Remaining flat for 3 hours
b. Breathing and coughing deeply
c. Eating a soft diet for 2 days
d. Avoiding bending from the waist
5. A client receiving hemodialysis has AV fistula for circulatory access. An important nursing
consideration in caring for this client is: *
,a. Preventing infection
b. Observing aseptic technique
c. Checking weight daily
d. Observing arm precaution
6. When a client develops a hemolytic transfusion reaction because of incompatible blood, the nurse
should assess the client for: *
a. Dyspnea
b. Backache
c. Cyanosis
d. Bradycardia
7. As a result of transfusion reaction, a client suffers kidney damage. When determining kidney damage,
the most significant clinical response that the nurse should assess is: *
a. Polyuria
b. Decreased urinary output
c. Hematuria
d. Acute pain over the kidney area
8. A client with acute renal failure complains of nausea, pain in the abdomen, diarrhea, and muscular
weakness. The nurse notes an irregularity in pulse and signs of pulmonary edema. These are probably
manifestations of: *
a. Calcium excess
b. Sodium deficiency
c. Potassium excess
d. Calcium deficiency
9. When caring for a client who is receiving peritoneal dialysis, the nurse should: *
a. Position the client from side to side if fluid is not draining properly
b. Notify the physician if there is a deficit of 200 ml in the drainage fluid
, c. Maintain the client in a flat, supine position during the entire procedure
d. Remove the cannula at the end of procedure and apply a dry, sterile dressing
10. The physician orders oxygen therapy via nasal cannula (nasal prongs) at two liters per minute for an
elderly client with heart failure. A priority nursing action would be to: *
a. Always maintain the client on bed rest
b. Investigate if the client has COPD
c. Determine if the client is a mouth breather
d. Obtain the oxygen saturation measurements
11. A client with a history of acute myocardial infarction complains about the lack of salt in the food. The
nurse should explain that the salt must be limited to: *
a. Prevent any rise in blood pressure from the tissue edema
b. Produce a diuretic effect and reduce the circulating blood volume
c. Reduce the amount of edema present, which interferes with the heart action
d. Prevent the further accumulation of fluid and increasing workload of the heart
12. A client has a diagnosis of acute cholecystitis with biliary colic. In addition to pain in the right upper
quadrant, the nurse should expect the client to have: *
a. Melena and diarrhea
b. Vomiting of coffee–ground emesis
c. An intolerance to foods high in lipids
d. Gnawing pain when the stomach is empty
13. Following a cholecystectomy, Mrs. Santillan should be assessed for signs of bleeding or hemorrhage.
These observations are made because: *
a. Prostaglandins are released at the surgical site
b. The inflammatory process interferes with platelet formation
c. Diaphragmatic excursion places pressure on the suture line
d. Blood clotting may be hindered by lack of vitamin K absorption
