Adult health 1 exam one practice ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
questions exam with correct ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers
The nurse is caring for a patient who has a massive burn
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
injury and possible hypovolemia.
||\\||\\ ||\\||\\ ||\\||\\
Which assessment data should be of most concern to the
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
nurse?
a. Urine output is 30 mL/hr.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
b. Blood pressure is 90/40 mm Hg.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
c. Oral fluid intake is 100 mL for 8 hours.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
d. Skin tenting over the sternum is prolonged. - correct
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers ✔✔ANS: B ||\\||\\ ||\\||\\
The blood pressure indicates that the patient may be
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
developing hypovolemic shock because ||\\||\\ ||\\||\\ ||\\||\\
of intravascular fluid loss because of the burn injury. This
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
finding will require immediate ||\\||\\ ||\\||\\ ||\\||\\
intervention to prevent the complications associated with ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
systemic hypoperfusion. The poor ||\\||\\ ||\\||\\ ||\\||\\
,oral intake, decreased urine output, and skin tenting all
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
indicate the need for increasing the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
patient's fluid intake but not as urgently as the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
hypotension.
DIF: Cognitive Level: Analyze (analysis)
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
TOP: Nursing Process: Assessment MSC: NCLEX: ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Physiological Integrity ||\\||\\
A patient who has a small cell cancer of the lung develops
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
syndrome of inappropriate ||\\||\\ ||\\||\\
antidiuretic hormone (SIADH). The nurse should notify the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
health care provider about which
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
assessment finding? ||\\||\\
a. Serum hematocrit of 42%
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
b. Serum sodium of 120 mg/dL
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
c. Urinary output of 280 mL in 8 hours
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
d. Reported weight gain of 2.2 pounds (1 kg) - correct
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers ✔✔ANS: B ||\\||\\ ||\\||\\
,Hyponatremia is the most important finding to report. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
SIADH causes water retention and a ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
decrease in serum sodium level. Hyponatremia can cause ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
confusion and other central nervous ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
system effects. A critically low value needs to be treated. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
At least 30 mL/hr of urine output
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
indicates adequate kidney function. The hematocrit level ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
is normal. Weight gain is expected
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
with SIADH because of water retention. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
DIF: Cognitive Level: Apply (application)
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
TOP: Nursing Process: Assessment MSC: NCLEX:
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Physiological Integrity ||\\||\\
A patient with multiple draining wounds is admitted for
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
hypovolemia. What would be the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
most accurate way for the nurse to evaluate fluid balance?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
a. Skin turgor
||\\||\\ ||\\||\\
b. Daily weight
||\\||\\ ||\\||\\
c. Urine output
||\\||\\ ||\\||\\
, d. Edema presence - correct answers ✔✔ANS: B
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Daily weight is the most easily obtained and accurate
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
means of assessing volume status. Skin ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
turgor varies considerably with age. Considerable excess ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
fluid volume may be present before ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
fluid moves into the interstitial space and causes edema.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Urine outputs do not take account of ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
fluid intake or of fluid loss through insensible loss,
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
sweating, or loss from the gastrointestinal ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
tract or wounds. ||\\||\\ ||\\||\\
DIF: Cognitive Level: Analyze (analysis) TOP: Nursing
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Process: Evaluation ||\\||\\
MSC: NCLEX: Physiological Integrity ||\\||\\ ||\\||\\ ||\\||\\
The home health nurse cares for an alert and oriented
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
older adult patient with a history of ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
dehydration. Which instructions should the nurse give this ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
patient related to fluid intake?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
a. "Drink more fluids in the late evening."
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
questions exam with correct ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers
The nurse is caring for a patient who has a massive burn
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
injury and possible hypovolemia.
||\\||\\ ||\\||\\ ||\\||\\
Which assessment data should be of most concern to the
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
nurse?
a. Urine output is 30 mL/hr.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
b. Blood pressure is 90/40 mm Hg.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
c. Oral fluid intake is 100 mL for 8 hours.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
d. Skin tenting over the sternum is prolonged. - correct
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers ✔✔ANS: B ||\\||\\ ||\\||\\
The blood pressure indicates that the patient may be
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
developing hypovolemic shock because ||\\||\\ ||\\||\\ ||\\||\\
of intravascular fluid loss because of the burn injury. This
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
finding will require immediate ||\\||\\ ||\\||\\ ||\\||\\
intervention to prevent the complications associated with ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
systemic hypoperfusion. The poor ||\\||\\ ||\\||\\ ||\\||\\
,oral intake, decreased urine output, and skin tenting all
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
indicate the need for increasing the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
patient's fluid intake but not as urgently as the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
hypotension.
DIF: Cognitive Level: Analyze (analysis)
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
TOP: Nursing Process: Assessment MSC: NCLEX: ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Physiological Integrity ||\\||\\
A patient who has a small cell cancer of the lung develops
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
syndrome of inappropriate ||\\||\\ ||\\||\\
antidiuretic hormone (SIADH). The nurse should notify the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
health care provider about which
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
assessment finding? ||\\||\\
a. Serum hematocrit of 42%
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
b. Serum sodium of 120 mg/dL
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
c. Urinary output of 280 mL in 8 hours
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
d. Reported weight gain of 2.2 pounds (1 kg) - correct
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers ✔✔ANS: B ||\\||\\ ||\\||\\
,Hyponatremia is the most important finding to report. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
SIADH causes water retention and a ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
decrease in serum sodium level. Hyponatremia can cause ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
confusion and other central nervous ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
system effects. A critically low value needs to be treated. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
At least 30 mL/hr of urine output
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
indicates adequate kidney function. The hematocrit level ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
is normal. Weight gain is expected
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
with SIADH because of water retention. ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
DIF: Cognitive Level: Apply (application)
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
TOP: Nursing Process: Assessment MSC: NCLEX:
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Physiological Integrity ||\\||\\
A patient with multiple draining wounds is admitted for
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
hypovolemia. What would be the ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
most accurate way for the nurse to evaluate fluid balance?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
a. Skin turgor
||\\||\\ ||\\||\\
b. Daily weight
||\\||\\ ||\\||\\
c. Urine output
||\\||\\ ||\\||\\
, d. Edema presence - correct answers ✔✔ANS: B
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Daily weight is the most easily obtained and accurate
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
means of assessing volume status. Skin ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
turgor varies considerably with age. Considerable excess ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
fluid volume may be present before ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
fluid moves into the interstitial space and causes edema.
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Urine outputs do not take account of ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
fluid intake or of fluid loss through insensible loss,
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
sweating, or loss from the gastrointestinal ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
tract or wounds. ||\\||\\ ||\\||\\
DIF: Cognitive Level: Analyze (analysis) TOP: Nursing
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Process: Evaluation ||\\||\\
MSC: NCLEX: Physiological Integrity ||\\||\\ ||\\||\\ ||\\||\\
The home health nurse cares for an alert and oriented
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
older adult patient with a history of ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
dehydration. Which instructions should the nurse give this ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
patient related to fluid intake?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
a. "Drink more fluids in the late evening."
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
