Adult Health 1 – Exam 4 | Newest 2026 Edition | Actual Exam
Questions, Verified Correct Answers & Expert Rationales |
Comprehensive Medical Surgical Nursing Success Study Guide |
Updated Review Pack | Instant PDF Download
1.A nurse is caring for a client who suddenly develops acute dyspnea, chest pain, and hemoptysis
two days after abdominal surgery. Which of the following is the most likely cause of these
manifestations?
A. Pneumothorax
B. Pulmonary embolism
C. Myocardial infarction
D. Atelectasis
B. Pulmonary embolism
Rationale: The triad of acute dyspnea, chest pain, and hemoptysis after surgery suggests a
pulmonary embolism, often from deep vein thrombosis. Postoperative immobility increases
risk.
2. A client with a fractured femur has been immobile for 48 hours. The nurse should assess for
which of the following as an early sign of a pulmonary embolism?
A. Sudden onset of pleuritic chest pain
B. Bradycardia
C. Hypotension
D. Hemoptysis
A. Sudden onset of pleuritic chest pain
Rationale: Sudden pleuritic chest pain is often the first sign of a pulmonary embolism.
Tachycardia and tachypnea also occur, but bradycardia is not typical.
3. A nurse is assessing a client with a suspected pulmonary embolism. Which of the following
findings should the nurse expect?
A. Bradypnea
B. Pleural friction rub
C. Hypertension
D. Petechiae
B. Pleural friction rub
,Rationale: A pleural friction rub occurs when the inflamed pleural surfaces rub together,
common in pulmonary embolism. Tachycardia and petechiae may also be present, but
bradypnea and hypertension are not typical.
4. A nurse is reviewing prescriptions for a client with acute dyspnea and diaphoresis. The client
states, "I am anxious and unable to get enough air." Vital signs are heart rate 117/min,
respirations 38/min, temperature 38.4°C, and blood pressure 100/54 mm Hg. Which of the
following nursing actions is the priority?
A. Notify the provider
B. Administer heparin via IV infusion
C. Administer oxygen therapy
D. Obtain a CT scan
C. Administer oxygen therapy
Rationale: Airway and breathing take priority. The client is hypoxic and anxious; oxygen
should be given immediately to improve oxygenation before other interventions.
5. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the
following statements by the client should indicate an immediate concern?
A. "I am allergic to morphine"
B. "I take antacids several times a day for my ulcer"
C. "I had a blood clot in my leg several years ago"
D. "It hurts to take a deep breath"
B. "I take antacids several times a day for my ulcer"
Rationale: Heparin is an anticoagulant and can increase bleeding risk. A history of peptic
ulcer disease is a relative contraindication due to the risk of gastrointestinal bleeding.
6. A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following
factors should the nurse recognize as a contraindication to the therapy?
A. Hip arthroplasty 2 weeks ago
B. Elevated sedimentation rate
C. Incident of exerciseinduced asthma 1 week ago
D. Elevated platelet count
A. Hip arthroplasty 2 weeks ago
Rationale: Major surgery within 2 weeks is a contraindication to thrombolytic therapy due to
the high risk of bleeding at the surgical site. Asthma and elevated platelets are not direct
contraindications.
7. A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed
for hemodynamic monitoring. Which of the following statements by the newly licensed nurse
indicates understanding?
A. "Air should be instilled into the monitoring system prior to the procedure"
B. "The client should be positioned on the left side during the procedure"
C. "The transducer should be level with the second intercostal space after the line is placed"
D. "A chest xray is needed to verify placement after the procedure"
D. "A chest xray is needed to verify placement after the procedure"
,Rationale: Chest xray confirms proper placement of hemodynamic lines such as pulmonary
artery catheters. Air should never be instilled; the phlebostatic axis is at the fourth intercostal
space.
8. A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a
CVP of 7 mm Hg and a PAWP of 17 mm Hg. Which of the following findings should the nurse
expect?
A. Poor skin turgor
B. Bilateral crackles in the lungs
C. Jugular vein distension
D. Dry mucous membranes
E. Hepatomegaly
B. Bilateral crackles in the lungs
C. Jugular vein distension
E. Hepatomegaly
Rationale: Elevated CVP and PAWP indicate fluid overload and heart failure. Crackles,
jugular distension, and hepatomegaly are signs of pulmonary and systemic congestion.
9. A nurse is teaching a client who is scheduled for coronary angiography. Which of the
following statements should the nurse include?
A. "You should have nothing to eat or drink for 4 hours prior to the procedure"
B. "You will be given general anesthesia during the procedure"
C. "You should not have this procedure done if you are allergic to eggs"
D. "You will need to keep your affected leg straight following the procedure"
D. "You will need to keep your affected leg straight following the procedure"
Rationale: After femoral artery access, the leg must be kept straight to prevent bleeding and
hematoma formation. General anesthesia is not used; contrast dye allergy (not eggs) is a
concern.
10. A nurse at a provider's office is reviewing the laboratory test results for a group of clients.
Which of the following results indicates the client is at risk for heart disease?
A. Cholesterol (total) 245 mg/dL
B. HDL 90 mg/dL
C. LDL 140 mg/dL
D. Triglycerides 125 mg/dL
E. Troponin I 0.02 ng/mL
A. Cholesterol (total) 245 mg/dL
C. LDL 140 mg/dL
Rationale: Total cholesterol >200 and LDL >130 increase cardiovascular risk. HDL >60 is
protective; triglycerides <150 and normal troponin are not risk factors.
11. A nurse is planning care for a client who has a PICC line in the right arm. Which of the
following interventions should the nurse include?
A. Use a 10 mL syringe to flush the PICC line
B. Apply gentle force if resistance is met during injection
, C. Cleanse ports with alcohol for 15 seconds prior to use
D. Maintain a transparent dressing over the insertion site
E. Flush with 10 mL heparin before and after medication administration
A. Use a 10 mL syringe to flush the PICC line
C. Cleanse ports with alcohol for 15 seconds prior to use
D. Maintain a transparent dressing over the insertion site
Rationale: 10 mL syringe minimizes pressure; alcohol scrubbing and transparent dressings
reduce infection risk. Never force resistance; heparin is not required for all PICCs.
12. A nurse is caring for a client who is 4 hours postoperative following coronary artery bypass
grafting (CABG) surgery. The client is able to inspire 200 mL with the incentive spirometer, then
declines to try to cough because of fatigue and pain. Which of the following actions should the
nurse take?
A. Allow the client to rest and return in 1 hour
B. Administer IV bolus analgesic, and return in 15 minutes
C. Document the 200 mL as an appropriate inspired volume
D. Tell the client coughing after incentive spirometry is required
B. Administer IV bolus analgesic, and return in 15 minutes
Rationale: Pain management is essential to promote effective coughing and deep breathing.
After analgesia, the client can perform the intervention more effectively.
13. A nurse is caring for a client following peripheral bypass graft surgery of the left lower
extremity. Which of the following findings pose an immediate concern?
A. Trace of bloody drainage on dressing
B. Capillary refill of affected limb of 6 seconds
C. Mottled appearance of the limb
D. Throbbing pain of affected limb that is decreased following IV bolus analgesic
E. Pulse of 2+ in the affected limb
B. Capillary refill of affected limb of 6 seconds
C. Mottled appearance of the limb
Rationale: Delayed capillary refill and mottling indicate ischemia and possible graft occlusion.
These require immediate intervention.
14. A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary
artery bypass grafting with a group of nurses. Which of the following statements should the
nurse include in the discussion?
A. "The client's demand for oxygen is lowered"
B. "Motion of the heart ceases"
C. "Rewarming of the client takes place"
D. "The client's metabolic rate is increased"
E. "Blood flow to the heart is stopped"
A. "The client's demand for oxygen is lowered"
B. "Motion of the heart ceases"
C. "Rewarming of the client takes place"
Questions, Verified Correct Answers & Expert Rationales |
Comprehensive Medical Surgical Nursing Success Study Guide |
Updated Review Pack | Instant PDF Download
1.A nurse is caring for a client who suddenly develops acute dyspnea, chest pain, and hemoptysis
two days after abdominal surgery. Which of the following is the most likely cause of these
manifestations?
A. Pneumothorax
B. Pulmonary embolism
C. Myocardial infarction
D. Atelectasis
B. Pulmonary embolism
Rationale: The triad of acute dyspnea, chest pain, and hemoptysis after surgery suggests a
pulmonary embolism, often from deep vein thrombosis. Postoperative immobility increases
risk.
2. A client with a fractured femur has been immobile for 48 hours. The nurse should assess for
which of the following as an early sign of a pulmonary embolism?
A. Sudden onset of pleuritic chest pain
B. Bradycardia
C. Hypotension
D. Hemoptysis
A. Sudden onset of pleuritic chest pain
Rationale: Sudden pleuritic chest pain is often the first sign of a pulmonary embolism.
Tachycardia and tachypnea also occur, but bradycardia is not typical.
3. A nurse is assessing a client with a suspected pulmonary embolism. Which of the following
findings should the nurse expect?
A. Bradypnea
B. Pleural friction rub
C. Hypertension
D. Petechiae
B. Pleural friction rub
,Rationale: A pleural friction rub occurs when the inflamed pleural surfaces rub together,
common in pulmonary embolism. Tachycardia and petechiae may also be present, but
bradypnea and hypertension are not typical.
4. A nurse is reviewing prescriptions for a client with acute dyspnea and diaphoresis. The client
states, "I am anxious and unable to get enough air." Vital signs are heart rate 117/min,
respirations 38/min, temperature 38.4°C, and blood pressure 100/54 mm Hg. Which of the
following nursing actions is the priority?
A. Notify the provider
B. Administer heparin via IV infusion
C. Administer oxygen therapy
D. Obtain a CT scan
C. Administer oxygen therapy
Rationale: Airway and breathing take priority. The client is hypoxic and anxious; oxygen
should be given immediately to improve oxygenation before other interventions.
5. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the
following statements by the client should indicate an immediate concern?
A. "I am allergic to morphine"
B. "I take antacids several times a day for my ulcer"
C. "I had a blood clot in my leg several years ago"
D. "It hurts to take a deep breath"
B. "I take antacids several times a day for my ulcer"
Rationale: Heparin is an anticoagulant and can increase bleeding risk. A history of peptic
ulcer disease is a relative contraindication due to the risk of gastrointestinal bleeding.
6. A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following
factors should the nurse recognize as a contraindication to the therapy?
A. Hip arthroplasty 2 weeks ago
B. Elevated sedimentation rate
C. Incident of exerciseinduced asthma 1 week ago
D. Elevated platelet count
A. Hip arthroplasty 2 weeks ago
Rationale: Major surgery within 2 weeks is a contraindication to thrombolytic therapy due to
the high risk of bleeding at the surgical site. Asthma and elevated platelets are not direct
contraindications.
7. A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed
for hemodynamic monitoring. Which of the following statements by the newly licensed nurse
indicates understanding?
A. "Air should be instilled into the monitoring system prior to the procedure"
B. "The client should be positioned on the left side during the procedure"
C. "The transducer should be level with the second intercostal space after the line is placed"
D. "A chest xray is needed to verify placement after the procedure"
D. "A chest xray is needed to verify placement after the procedure"
,Rationale: Chest xray confirms proper placement of hemodynamic lines such as pulmonary
artery catheters. Air should never be instilled; the phlebostatic axis is at the fourth intercostal
space.
8. A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a
CVP of 7 mm Hg and a PAWP of 17 mm Hg. Which of the following findings should the nurse
expect?
A. Poor skin turgor
B. Bilateral crackles in the lungs
C. Jugular vein distension
D. Dry mucous membranes
E. Hepatomegaly
B. Bilateral crackles in the lungs
C. Jugular vein distension
E. Hepatomegaly
Rationale: Elevated CVP and PAWP indicate fluid overload and heart failure. Crackles,
jugular distension, and hepatomegaly are signs of pulmonary and systemic congestion.
9. A nurse is teaching a client who is scheduled for coronary angiography. Which of the
following statements should the nurse include?
A. "You should have nothing to eat or drink for 4 hours prior to the procedure"
B. "You will be given general anesthesia during the procedure"
C. "You should not have this procedure done if you are allergic to eggs"
D. "You will need to keep your affected leg straight following the procedure"
D. "You will need to keep your affected leg straight following the procedure"
Rationale: After femoral artery access, the leg must be kept straight to prevent bleeding and
hematoma formation. General anesthesia is not used; contrast dye allergy (not eggs) is a
concern.
10. A nurse at a provider's office is reviewing the laboratory test results for a group of clients.
Which of the following results indicates the client is at risk for heart disease?
A. Cholesterol (total) 245 mg/dL
B. HDL 90 mg/dL
C. LDL 140 mg/dL
D. Triglycerides 125 mg/dL
E. Troponin I 0.02 ng/mL
A. Cholesterol (total) 245 mg/dL
C. LDL 140 mg/dL
Rationale: Total cholesterol >200 and LDL >130 increase cardiovascular risk. HDL >60 is
protective; triglycerides <150 and normal troponin are not risk factors.
11. A nurse is planning care for a client who has a PICC line in the right arm. Which of the
following interventions should the nurse include?
A. Use a 10 mL syringe to flush the PICC line
B. Apply gentle force if resistance is met during injection
, C. Cleanse ports with alcohol for 15 seconds prior to use
D. Maintain a transparent dressing over the insertion site
E. Flush with 10 mL heparin before and after medication administration
A. Use a 10 mL syringe to flush the PICC line
C. Cleanse ports with alcohol for 15 seconds prior to use
D. Maintain a transparent dressing over the insertion site
Rationale: 10 mL syringe minimizes pressure; alcohol scrubbing and transparent dressings
reduce infection risk. Never force resistance; heparin is not required for all PICCs.
12. A nurse is caring for a client who is 4 hours postoperative following coronary artery bypass
grafting (CABG) surgery. The client is able to inspire 200 mL with the incentive spirometer, then
declines to try to cough because of fatigue and pain. Which of the following actions should the
nurse take?
A. Allow the client to rest and return in 1 hour
B. Administer IV bolus analgesic, and return in 15 minutes
C. Document the 200 mL as an appropriate inspired volume
D. Tell the client coughing after incentive spirometry is required
B. Administer IV bolus analgesic, and return in 15 minutes
Rationale: Pain management is essential to promote effective coughing and deep breathing.
After analgesia, the client can perform the intervention more effectively.
13. A nurse is caring for a client following peripheral bypass graft surgery of the left lower
extremity. Which of the following findings pose an immediate concern?
A. Trace of bloody drainage on dressing
B. Capillary refill of affected limb of 6 seconds
C. Mottled appearance of the limb
D. Throbbing pain of affected limb that is decreased following IV bolus analgesic
E. Pulse of 2+ in the affected limb
B. Capillary refill of affected limb of 6 seconds
C. Mottled appearance of the limb
Rationale: Delayed capillary refill and mottling indicate ischemia and possible graft occlusion.
These require immediate intervention.
14. A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary
artery bypass grafting with a group of nurses. Which of the following statements should the
nurse include in the discussion?
A. "The client's demand for oxygen is lowered"
B. "Motion of the heart ceases"
C. "Rewarming of the client takes place"
D. "The client's metabolic rate is increased"
E. "Blood flow to the heart is stopped"
A. "The client's demand for oxygen is lowered"
B. "Motion of the heart ceases"
C. "Rewarming of the client takes place"
