PN ADULT MEDICAL EVALUATION ANSWERS AND
QUESTIONS SET A+
✔✔A nurse is collecting data from an older adult client who has received a scheduled
opioid analgesic and is now confused and appears drowsy. Which of the following
actions should the nurse take? (SATA) - ✔✔-Measure the client's SaO2
-Instruct the client in the use of the call light
-Apply an ambulation alarm to the client's leg
✔✔A nurse is caring for a client who is postoperative following a below-the-knee
amputation. Which of the following client actions indicates that the client is struggling to
accept their body image change? - ✔✔The client looks away during dressing changes.
✔✔A nurse is reinforcing teaching w/ a client who has prescription for periodic aPTT
testing. Which of the following client statements indicates an understanding of the
teaching? - ✔✔"This test measures the effectiveness of clotting factors."
✔✔A nurse is reviewing the medical record for a client who has sepsis. Which of the
following findings is the priorty to report to the provider? (Three exhibit tabs for a record
review.) - ✔✔Blood pressure
✔✔A nurse is caring for a client who has been receiving potassium chloride after being
admitted w/ a serum potassium of 3.1 mEq/L. Which of the following findings should the
nurse identify as a therapeutic response to treatment? - ✔✔Increased muscle strength
✔✔A nurse is preparing to provide care for a group of clients. Which of the following
clients should the nurse see first? - ✔✔A client who has blood glucose of 67 mg/dL and
reports mild sweating.
✔✔A nurse is collecting data from a client who has malnutrition. Which of the following
findings should the nurse identify as an indication of malnutrition? - ✔✔Decreased
mental status.
, ✔✔A nurse is reinforcing teaching w/ a client who has a prescription for fluoxetine to
treat major depressive disorder. Which of the following manifestations should the nurse
include as an adverse effect of fluoxetine? - ✔✔Sexual dysfunction
✔✔A nurse is observing an assistive personnel (AP) providing care for a group of
clients. For which of the following actions by the AP should the nurse intervene? -
✔✔The AP offers a client a drink of cool water 1 hr before a scheduled liver biopsy.
✔✔A nurse is reviewing the ABG findings of a client who has COPD and was admitted
w/ pneumonia. Which of the following ABG results should the nurse anticipate? - ✔✔pH
7.33; PaCO2 58 mm Hg; HCO3- 25 mEq/L
✔✔A nurse is contributing to the plan of care for a client who has a halo stabilization
device. Which of the following interventions should the nurse include in the plan? -
✔✔Provide pin site care every shift.
✔✔A nurse is contributing to the plan of care for a client who has neutropenia following
chemotherapy. Which of the following interventions should the nurse recommend for the
client's plan of care? - ✔✔Reinforce teaching about deep breathing exercises.
✔✔A nurse is collecting data from a client who is receiving long-term glucocorticoid
therapy to treat lupus erythematosus (LE). The nurse should recognize that which of the
following findings is an adverse effect of long-term glucocorticoid therapy? - ✔✔Moon
face
✔✔A nurse is collecting data from a client who has a new prescription for metoprolol.
The nurse should identify that which of the following findings is an adverse effect of this
medication? - ✔✔Bradycardia
✔✔A nurse is reinforcing teaching w/ a client about managing hearing loss. Which of
the following statements by the client indicates an understanding of the teaching? -
✔✔"It can a several weeks to adjust to a hearing aid when it is first used."
✔✔A nurse is collecting data from a client who has been taking lithium for 3 months.
Which of the following findings is the priority to report to the provider? - ✔✔Blurred
vision
✔✔A nurse is caring for a client who had a lumbar laminectomy and has a prescription
for an oral opioid analgesic. Which of the following actions should the nurse take? -
✔✔ecommend the client increase their intake of fiber-rich foods.
QUESTIONS SET A+
✔✔A nurse is collecting data from an older adult client who has received a scheduled
opioid analgesic and is now confused and appears drowsy. Which of the following
actions should the nurse take? (SATA) - ✔✔-Measure the client's SaO2
-Instruct the client in the use of the call light
-Apply an ambulation alarm to the client's leg
✔✔A nurse is caring for a client who is postoperative following a below-the-knee
amputation. Which of the following client actions indicates that the client is struggling to
accept their body image change? - ✔✔The client looks away during dressing changes.
✔✔A nurse is reinforcing teaching w/ a client who has prescription for periodic aPTT
testing. Which of the following client statements indicates an understanding of the
teaching? - ✔✔"This test measures the effectiveness of clotting factors."
✔✔A nurse is reviewing the medical record for a client who has sepsis. Which of the
following findings is the priorty to report to the provider? (Three exhibit tabs for a record
review.) - ✔✔Blood pressure
✔✔A nurse is caring for a client who has been receiving potassium chloride after being
admitted w/ a serum potassium of 3.1 mEq/L. Which of the following findings should the
nurse identify as a therapeutic response to treatment? - ✔✔Increased muscle strength
✔✔A nurse is preparing to provide care for a group of clients. Which of the following
clients should the nurse see first? - ✔✔A client who has blood glucose of 67 mg/dL and
reports mild sweating.
✔✔A nurse is collecting data from a client who has malnutrition. Which of the following
findings should the nurse identify as an indication of malnutrition? - ✔✔Decreased
mental status.
, ✔✔A nurse is reinforcing teaching w/ a client who has a prescription for fluoxetine to
treat major depressive disorder. Which of the following manifestations should the nurse
include as an adverse effect of fluoxetine? - ✔✔Sexual dysfunction
✔✔A nurse is observing an assistive personnel (AP) providing care for a group of
clients. For which of the following actions by the AP should the nurse intervene? -
✔✔The AP offers a client a drink of cool water 1 hr before a scheduled liver biopsy.
✔✔A nurse is reviewing the ABG findings of a client who has COPD and was admitted
w/ pneumonia. Which of the following ABG results should the nurse anticipate? - ✔✔pH
7.33; PaCO2 58 mm Hg; HCO3- 25 mEq/L
✔✔A nurse is contributing to the plan of care for a client who has a halo stabilization
device. Which of the following interventions should the nurse include in the plan? -
✔✔Provide pin site care every shift.
✔✔A nurse is contributing to the plan of care for a client who has neutropenia following
chemotherapy. Which of the following interventions should the nurse recommend for the
client's plan of care? - ✔✔Reinforce teaching about deep breathing exercises.
✔✔A nurse is collecting data from a client who is receiving long-term glucocorticoid
therapy to treat lupus erythematosus (LE). The nurse should recognize that which of the
following findings is an adverse effect of long-term glucocorticoid therapy? - ✔✔Moon
face
✔✔A nurse is collecting data from a client who has a new prescription for metoprolol.
The nurse should identify that which of the following findings is an adverse effect of this
medication? - ✔✔Bradycardia
✔✔A nurse is reinforcing teaching w/ a client about managing hearing loss. Which of
the following statements by the client indicates an understanding of the teaching? -
✔✔"It can a several weeks to adjust to a hearing aid when it is first used."
✔✔A nurse is collecting data from a client who has been taking lithium for 3 months.
Which of the following findings is the priority to report to the provider? - ✔✔Blurred
vision
✔✔A nurse is caring for a client who had a lumbar laminectomy and has a prescription
for an oral opioid analgesic. Which of the following actions should the nurse take? -
✔✔ecommend the client increase their intake of fiber-rich foods.
