ADULT HEALTH 1 PRACTICE EXAM
QUESTIONS WITH CORRECT
ANSWERS
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."
b. "More fluids are needed if you feel thirsty."
c. "Increase the fluids if your mouth feels dry."
d. "If you feel confused, you need more fluids."
ANS: C
An alert older patient will be able to self-assess for signs of oral dryness such
as thick oral
secretions or dry-appearing mucosa. The thirst mechanism decreases with
age and is not an
accurate indicator of volume depletion. Many older patients prefer to restrict
fluids slightly in
the evening to improve sleep quality. The patient will not be likely to notice
and act
appropriately when changes in level of consciousness occur.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and
Maintenance
,A patient who is taking a potassium-wasting diuretic for treatment of
hypertension reports
generalized weakness. Which action is appropriate for the nurse to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.
ANS: D
Generalized weakness is a manifestation of hypokalemia. After the health
care provider orders
the metabolic panel, the nurse should check the potassium level. Facial
muscle spasms might
occur with hypocalcemia. Orange juice is high in potassium and would be
advisable to drink
if the patient is hypokalemic. Loose stools are associated with hyperkalemia.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a
patient. Which
statement by the patient indicates that the teaching about this medication
has been effective?
a. "I will try to drink at least 8 glasses of water every day."
b. "I will use a salt substitute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast."
,ANS: D
Because spironolactone is a potassium-sparing diuretic, teach patients to
choose
low-potassium foods (e.g., apple juice) rather than foods that have higher
levels of potassium
(e.g., citrus fruits). Because the patient is using spironolactone as a diuretic,
the nurse would
not encourage the patient to increase fluid intake. Teach patients to avoid
salt substitutes,
which are high in potassium.
DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
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.
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)
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
QUESTIONS WITH CORRECT
ANSWERS
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."
b. "More fluids are needed if you feel thirsty."
c. "Increase the fluids if your mouth feels dry."
d. "If you feel confused, you need more fluids."
ANS: C
An alert older patient will be able to self-assess for signs of oral dryness such
as thick oral
secretions or dry-appearing mucosa. The thirst mechanism decreases with
age and is not an
accurate indicator of volume depletion. Many older patients prefer to restrict
fluids slightly in
the evening to improve sleep quality. The patient will not be likely to notice
and act
appropriately when changes in level of consciousness occur.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and
Maintenance
,A patient who is taking a potassium-wasting diuretic for treatment of
hypertension reports
generalized weakness. Which action is appropriate for the nurse to take?
a. Assess for facial muscle spasms.
b. Ask the patient about loose stools.
c. Recommend the patient avoid drinking orange juice with meals.
d. Suggest that the health care provider order a basic metabolic panel.
ANS: D
Generalized weakness is a manifestation of hypokalemia. After the health
care provider orders
the metabolic panel, the nurse should check the potassium level. Facial
muscle spasms might
occur with hypocalcemia. Orange juice is high in potassium and would be
advisable to drink
if the patient is hypokalemic. Loose stools are associated with hyperkalemia.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a
patient. Which
statement by the patient indicates that the teaching about this medication
has been effective?
a. "I will try to drink at least 8 glasses of water every day."
b. "I will use a salt substitute to decrease my sodium intake."
c. "I will increase my intake of potassium-containing foods."
d. "I will drink apple juice instead of orange juice for breakfast."
,ANS: D
Because spironolactone is a potassium-sparing diuretic, teach patients to
choose
low-potassium foods (e.g., apple juice) rather than foods that have higher
levels of potassium
(e.g., citrus fruits). Because the patient is using spironolactone as a diuretic,
the nurse would
not encourage the patient to increase fluid intake. Teach patients to avoid
salt substitutes,
which are high in potassium.
DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
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.
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)
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
