ADULT HEALTH NURSING COMPREHENSIVE REVIEW
JULY 2027 (QUESTIONS and ANSWERS)
[1] A 68-year-old male with a history of hypertension and type 2
diabetes mellitus is admitted with acute decompensated heart failure.
He is receiving IV furosemide. Which assessment finding is the most
critical to report to the healthcare provider immediately?
A. Serum potassium level of 3.2 mEq/L
B. Urine output of 40 mL in the last hour
C. Blood pressure of 138/86 mmHg
D. Mild dyspnea on exertion
Correct Answer: A
Explanation: Furosemide is a loop diuretic that can cause significant
hypokalemia. A serum potassium of 3.2 mEq/L is critically low and
increases the risk of fatal cardiac dysrhythmias, especially in a patient
with underlying cardiac disease. The other options are expected or less
urgent findings.
[2] A patient is receiving a continuous heparin infusion for a deep vein
thrombosis. The nurse reviews the aPTT results, which are 98 seconds
(control 28 seconds). What is the most appropriate nursing action?
A. Continue the infusion at the same rate
B. Increase the infusion rate per protocol
C. Decrease the infusion rate per protocol
D. Stop the infusion and prepare to administer protamine sulfate
Correct Answer: D
,Explanation: The therapeutic aPTT goal for heparin therapy is typically
1.5 to 2.5 times the control, which would be 42–70 seconds. A result of
98 seconds is dangerously high and indicates an increased risk of
bleeding. The nurse should stop the infusion and prepare to administer
protamine sulfate, the antidote. Continuing or adjusting the rate would
be unsafe.
[3] A nurse is caring for a patient with a chest tube connected to a
three-chamber water-seal drainage system. The nurse notices
continuous bubbling in the water-seal chamber. What is the most
appropriate initial action?
A. Clamp the chest tube immediately
B. Assess the system for an air leak
C. Document the finding as a normal occurrence
D. Increase the suction pressure
Correct Answer: B
Explanation: Continuous bubbling in the water-seal chamber indicates
an air leak. The nurse should first assess the system for a source of the
leak, starting by checking all connections. Clamping the tube could lead
to a tension pneumothorax. Intermittent bubbling is normal.
[4] A patient is 24 hours post-operative following a total hip
arthroplasty. Which intervention is most important to prevent venous
thromboembolism?
A. Apply sequential compression devices (SCDs)
B. Administer prescribed low-molecular-weight heparin
C. Place a pillow between the patient's legs
,D. Perform passive range-of-motion exercises
Correct Answer: B
Explanation: Pharmacological prophylaxis with anticoagulants such as
low-molecular-weight heparin is the most effective intervention to
prevent venous thromboembolism in high-risk post-operative patients.
SCDs and exercises are adjunctive but not the primary means of
prevention.
[5] During a shift assessment, the nurse notes that a patient with a
tracheostomy has a heart rate of 120 bpm, respiratory rate of 34
breaths/min, and oxygen saturation of 88% on 40% oxygen. The patient
is restless and has audible stridor. What is the priority nursing action?
A. Suction the tracheostomy tube
B. Increase the oxygen delivery to 100%
C. Call the rapid response team
D. Deflate the tracheostomy cuff
Correct Answer: A
Explanation: The patient is exhibiting signs of acute respiratory distress,
including tachypnea, tachycardia, hypoxia, and stridor. This is most likely
due to a mucous plug or obstruction. Suctioning the tracheostomy is the
priority to clear the airway. Increasing oxygen without clearing the
obstruction is insufficient.
[6] A patient with heart failure is prescribed digoxin. Which of the
following is a sign of digoxin toxicity that the nurse should monitor for?
A. Tachycardia
B. Hyperkalemia
, C. Visual disturbances (e.g., yellow or green halos)
D. Hypertension
Correct Answer: C
Explanation: Visual disturbances, such as seeing yellow or green halos
(xanthopsia), are classic signs of digoxin toxicity. Other signs include
bradycardia, nausea, vomiting, and hypokalemia. Tachycardia is not a
typical sign.
[7] The nurse is assessing a patient with a suspected pulmonary
embolism. Which finding is considered a classic sign?
A. Bradypnea
B. Pleuritic chest pain
C. Hypertension
D. Productive cough
Correct Answer: B
Explanation: Pleuritic chest pain is a classic finding of pulmonary
embolism due to pleural irritation. Other common signs include
tachypnea, tachycardia, and hypoxemia. Hypotension, not hypertension,
can occur. A productive cough is not a classic sign.
[8] A patient is being discharged with a prescription for warfarin. Which
statement by the patient indicates a need for further teaching?
A. "I will avoid eating large amounts of leafy green vegetables."
B. "I will take my medication at the same time every day."
C. "I will use a soft-bristled toothbrush."
D. "I will take ibuprofen for my occasional headaches."
Correct Answer: D
JULY 2027 (QUESTIONS and ANSWERS)
[1] A 68-year-old male with a history of hypertension and type 2
diabetes mellitus is admitted with acute decompensated heart failure.
He is receiving IV furosemide. Which assessment finding is the most
critical to report to the healthcare provider immediately?
A. Serum potassium level of 3.2 mEq/L
B. Urine output of 40 mL in the last hour
C. Blood pressure of 138/86 mmHg
D. Mild dyspnea on exertion
Correct Answer: A
Explanation: Furosemide is a loop diuretic that can cause significant
hypokalemia. A serum potassium of 3.2 mEq/L is critically low and
increases the risk of fatal cardiac dysrhythmias, especially in a patient
with underlying cardiac disease. The other options are expected or less
urgent findings.
[2] A patient is receiving a continuous heparin infusion for a deep vein
thrombosis. The nurse reviews the aPTT results, which are 98 seconds
(control 28 seconds). What is the most appropriate nursing action?
A. Continue the infusion at the same rate
B. Increase the infusion rate per protocol
C. Decrease the infusion rate per protocol
D. Stop the infusion and prepare to administer protamine sulfate
Correct Answer: D
,Explanation: The therapeutic aPTT goal for heparin therapy is typically
1.5 to 2.5 times the control, which would be 42–70 seconds. A result of
98 seconds is dangerously high and indicates an increased risk of
bleeding. The nurse should stop the infusion and prepare to administer
protamine sulfate, the antidote. Continuing or adjusting the rate would
be unsafe.
[3] A nurse is caring for a patient with a chest tube connected to a
three-chamber water-seal drainage system. The nurse notices
continuous bubbling in the water-seal chamber. What is the most
appropriate initial action?
A. Clamp the chest tube immediately
B. Assess the system for an air leak
C. Document the finding as a normal occurrence
D. Increase the suction pressure
Correct Answer: B
Explanation: Continuous bubbling in the water-seal chamber indicates
an air leak. The nurse should first assess the system for a source of the
leak, starting by checking all connections. Clamping the tube could lead
to a tension pneumothorax. Intermittent bubbling is normal.
[4] A patient is 24 hours post-operative following a total hip
arthroplasty. Which intervention is most important to prevent venous
thromboembolism?
A. Apply sequential compression devices (SCDs)
B. Administer prescribed low-molecular-weight heparin
C. Place a pillow between the patient's legs
,D. Perform passive range-of-motion exercises
Correct Answer: B
Explanation: Pharmacological prophylaxis with anticoagulants such as
low-molecular-weight heparin is the most effective intervention to
prevent venous thromboembolism in high-risk post-operative patients.
SCDs and exercises are adjunctive but not the primary means of
prevention.
[5] During a shift assessment, the nurse notes that a patient with a
tracheostomy has a heart rate of 120 bpm, respiratory rate of 34
breaths/min, and oxygen saturation of 88% on 40% oxygen. The patient
is restless and has audible stridor. What is the priority nursing action?
A. Suction the tracheostomy tube
B. Increase the oxygen delivery to 100%
C. Call the rapid response team
D. Deflate the tracheostomy cuff
Correct Answer: A
Explanation: The patient is exhibiting signs of acute respiratory distress,
including tachypnea, tachycardia, hypoxia, and stridor. This is most likely
due to a mucous plug or obstruction. Suctioning the tracheostomy is the
priority to clear the airway. Increasing oxygen without clearing the
obstruction is insufficient.
[6] A patient with heart failure is prescribed digoxin. Which of the
following is a sign of digoxin toxicity that the nurse should monitor for?
A. Tachycardia
B. Hyperkalemia
, C. Visual disturbances (e.g., yellow or green halos)
D. Hypertension
Correct Answer: C
Explanation: Visual disturbances, such as seeing yellow or green halos
(xanthopsia), are classic signs of digoxin toxicity. Other signs include
bradycardia, nausea, vomiting, and hypokalemia. Tachycardia is not a
typical sign.
[7] The nurse is assessing a patient with a suspected pulmonary
embolism. Which finding is considered a classic sign?
A. Bradypnea
B. Pleuritic chest pain
C. Hypertension
D. Productive cough
Correct Answer: B
Explanation: Pleuritic chest pain is a classic finding of pulmonary
embolism due to pleural irritation. Other common signs include
tachypnea, tachycardia, and hypoxemia. Hypotension, not hypertension,
can occur. A productive cough is not a classic sign.
[8] A patient is being discharged with a prescription for warfarin. Which
statement by the patient indicates a need for further teaching?
A. "I will avoid eating large amounts of leafy green vegetables."
B. "I will take my medication at the same time every day."
C. "I will use a soft-bristled toothbrush."
D. "I will take ibuprofen for my occasional headaches."
Correct Answer: D
