Final Exam Adult Health 1 NU 216 Questions With
Complete Solutions
ANS: 6, 2, 3, 1, 5, 4, 7.
Correct Order:
1. Assess area of skin to be used as puncture site
2. Identify patient using two identifiers
3. Check code on test strip vial
4. Clean puncture site with antiseptic solution
5. Gently squeeze fingertips until drop of blood appears
6. Wick blood drop into test strip
7. Read results and document in medical record
Rationale: Blood glucose should be monitored every 6 hours for
a patient receiving TPN. The skill begins with assessment of the
patient's skin to identify an appropriate puncture site. The final
step is documentation of the results in the patient's medical
record. Correct Answers The nurse is performing blood
glucose monitoring for a patient receiving parenteral nutrition.
Place the steps of the procedure in the correct sequence.
1. Clean puncture site with antiseptic solution.
2. Identify patient using two identifiers.
3. Check code on test strip vial.
4. Wick blood drop into test strip.
5. Gently squeeze fingertip until drop of blood appears.
6. Assess area of skin to be used as puncture site.
7. Read results and document in medical record.
,ANS: A, B, C
Rationale: These are the correct answers because they affect the
client's vision, factors affecting sensations in the legs and feet,
and a history of falls. There is no research to connect the risk of
falls with either of the skin conditions mentioned. Tai Chi
improves balance, which decreases risk for falls. Correct
Answers Which assessment finding is a contributor to an older
adult's risk for falls? (Select all that apply)
A. Client is awaiting cataract surgery on right eye
B. Client's type 2 diabetes is poorly controlled with diet and
exercise alone
C. Client reports a fall in the last year
D. Client has a history of contact dermatitis and psoriasis
E. Client attends Tai Chi classes
ANS: A, B, C Correct Answers A nurse is caring for an older
adult client. The nurse should recognize the client is at risk for
which of the following physiological changes? (Select all that
apply)
A. Decreased gastric motility
B. Decreased skin elasticity
C. Increased pain threshold
D. Increased metabolic rate
E. Increased cardiac output
ANS: A, B, C, E
,Rationale: Expected physiologic changes of aging include more
difficulty seeing due to greater sensitivity to glare, decreased
cough reflex, decreased bladder capacity, dehydration of
intervertebral disc. Correct Answers A nurse is teaching a class
of older adults about the expected physiologic changes of aging.
Which of the following changes should the nurse include in the
discussion? (Select all that apply.)
A. More difficulty seeing due to a greater sensitivity to glare
B. Decreased cough reflex
C. Decreased bladder capacity
D. Decreased systolic blood pressure
E. Dehydration of intervertebral disc
ANS: A, B, D
Rationale: A continuous passive motion device promotes motion
in the knee and prevents scar tissue formation. The nurse should
assess the strength of the pulses of both lower extremities to
help determine adequate circulation. A pillow should not be
placed behind the knee to avoid flexion contractures. The nurse
should prevent pressure ulcers on the client's heels by elevating
the heels off the bed with a pillow. The nurse should apply cold
therapy, not heat therapy, to reduce postoperative swelling.
Correct Answers A nurse is admitting a client to the orthopedic
unit following a total knee arthroplasty. Which of the following
actions by the nurse are appropriate? (Select all that apply.)
A. Maintain continuous passive motion device.
B. Palpate dorso-pedal pulses.
C. Place pillow behind the knee.
, D. Elevate heels off bed.
E. Apply heat therapy to incision.
ANS: A, B, E
Rationale: Inactivity, Family history, and Cigarette smoking
Correct Answers A nurse is teaching a group of women about
risk factors for developing osteoporosis. Which of the following
risk factors should the nurse include? (Select all that apply)
A. Inactivity
B. Family history
C. Obesity
D. Hyperlipidemia
E. Cigarette smoking
ANS: A, B, E, F
Rationale: Signs and symptoms of fluid overload include
increased pulse rate, distended neck veins, increased blood
pressure, pale and cool skin, skeletal muscle weakness, and
visual disturbances. Decreased blood pressure would be seen in
dehydration. Warm and pink skin is normal finding Correct
Answers A nurse assesses a client who is admitted for treatment
to fluid overload. Which sign and symptom does the nurse
expect to find?
A. Increased pulse rate
B. Distended neck veins
C. Decreased blood pressure
D. Warm and pink skin
Complete Solutions
ANS: 6, 2, 3, 1, 5, 4, 7.
Correct Order:
1. Assess area of skin to be used as puncture site
2. Identify patient using two identifiers
3. Check code on test strip vial
4. Clean puncture site with antiseptic solution
5. Gently squeeze fingertips until drop of blood appears
6. Wick blood drop into test strip
7. Read results and document in medical record
Rationale: Blood glucose should be monitored every 6 hours for
a patient receiving TPN. The skill begins with assessment of the
patient's skin to identify an appropriate puncture site. The final
step is documentation of the results in the patient's medical
record. Correct Answers The nurse is performing blood
glucose monitoring for a patient receiving parenteral nutrition.
Place the steps of the procedure in the correct sequence.
1. Clean puncture site with antiseptic solution.
2. Identify patient using two identifiers.
3. Check code on test strip vial.
4. Wick blood drop into test strip.
5. Gently squeeze fingertip until drop of blood appears.
6. Assess area of skin to be used as puncture site.
7. Read results and document in medical record.
,ANS: A, B, C
Rationale: These are the correct answers because they affect the
client's vision, factors affecting sensations in the legs and feet,
and a history of falls. There is no research to connect the risk of
falls with either of the skin conditions mentioned. Tai Chi
improves balance, which decreases risk for falls. Correct
Answers Which assessment finding is a contributor to an older
adult's risk for falls? (Select all that apply)
A. Client is awaiting cataract surgery on right eye
B. Client's type 2 diabetes is poorly controlled with diet and
exercise alone
C. Client reports a fall in the last year
D. Client has a history of contact dermatitis and psoriasis
E. Client attends Tai Chi classes
ANS: A, B, C Correct Answers A nurse is caring for an older
adult client. The nurse should recognize the client is at risk for
which of the following physiological changes? (Select all that
apply)
A. Decreased gastric motility
B. Decreased skin elasticity
C. Increased pain threshold
D. Increased metabolic rate
E. Increased cardiac output
ANS: A, B, C, E
,Rationale: Expected physiologic changes of aging include more
difficulty seeing due to greater sensitivity to glare, decreased
cough reflex, decreased bladder capacity, dehydration of
intervertebral disc. Correct Answers A nurse is teaching a class
of older adults about the expected physiologic changes of aging.
Which of the following changes should the nurse include in the
discussion? (Select all that apply.)
A. More difficulty seeing due to a greater sensitivity to glare
B. Decreased cough reflex
C. Decreased bladder capacity
D. Decreased systolic blood pressure
E. Dehydration of intervertebral disc
ANS: A, B, D
Rationale: A continuous passive motion device promotes motion
in the knee and prevents scar tissue formation. The nurse should
assess the strength of the pulses of both lower extremities to
help determine adequate circulation. A pillow should not be
placed behind the knee to avoid flexion contractures. The nurse
should prevent pressure ulcers on the client's heels by elevating
the heels off the bed with a pillow. The nurse should apply cold
therapy, not heat therapy, to reduce postoperative swelling.
Correct Answers A nurse is admitting a client to the orthopedic
unit following a total knee arthroplasty. Which of the following
actions by the nurse are appropriate? (Select all that apply.)
A. Maintain continuous passive motion device.
B. Palpate dorso-pedal pulses.
C. Place pillow behind the knee.
, D. Elevate heels off bed.
E. Apply heat therapy to incision.
ANS: A, B, E
Rationale: Inactivity, Family history, and Cigarette smoking
Correct Answers A nurse is teaching a group of women about
risk factors for developing osteoporosis. Which of the following
risk factors should the nurse include? (Select all that apply)
A. Inactivity
B. Family history
C. Obesity
D. Hyperlipidemia
E. Cigarette smoking
ANS: A, B, E, F
Rationale: Signs and symptoms of fluid overload include
increased pulse rate, distended neck veins, increased blood
pressure, pale and cool skin, skeletal muscle weakness, and
visual disturbances. Decreased blood pressure would be seen in
dehydration. Warm and pink skin is normal finding Correct
Answers A nurse assesses a client who is admitted for treatment
to fluid overload. Which sign and symptom does the nurse
expect to find?
A. Increased pulse rate
B. Distended neck veins
C. Decreased blood pressure
D. Warm and pink skin
