Adult Health III
Objective Assessment
(2 Full Exams)
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,Table of Contents
D454 OA EXAM SET 1 ............................................................ 2
D454 OA EXAM SET 2 .......................................................... 37
D454 AH III EXAM HINTS .................................................... 94
D454 AH III Study Guide Qs w/ Ans .................................. 113
D454 OA EXAM SET 1
Question 1
The nurse is assessing a burn victim who suffered destruction of the epidermis and
some of the dermis of the entire right arm and half of the length of the right leg. How
should the nurse document the burn assessment findings?
A. Superficial, 18% total body surface area (TBSA)
B. Superficial partial thickness, 18% TBSA
C. Deep partial thickness, 27% TBSA
D. Full thickness, 27% TBSA
Correc Answer:
B. Superficial partial thickness, 18% TBSA
Rationale: A superficial partial-thickness burn involves destruction of the epidermis layer
and some of the dermis layer. The %TBSA is easily calculated by using the rule of nines
, method. In this case, involvement of one arm is calculated as 9% TBSA, one-half of a leg
is 9% TBSA, for a combined total of 18% TBSA. Total leg involvement is 18% TBSA.
Question 2
A client with a history of chronic alcoholism is admitted with pneumonia. The nurse
inserts two large bore IV catheters and starts an infusion of 0.9% sodium chloride at 75
mL/hour and titrates the client's oxygen to 60% by nonrebreather mask. The cardiac
monitor displays sinus tachycardia with multifocal premature ventricular contractions.
Which client's serum laboratory value requires immediate intervention by the nurse?
A. Sodium 138 mEq/L
B. Hemoglobin 9 g/dL
C. Magnesium 1.0 mg/dL
D. Potassium 5.5 mEq/L
Correc Answer:
C. Magnesium 1.0 mg/dL
Rationale: Normal magnesium level is 1.7 to 2.2 mg/dL. Hypomagnesemia is critical and
may cause a lethal ventricular arrhythmia, torsades de pointes, and requires immediate
intervention. Chronic alcoholism is a risk factor for hypomagnesemia due to poor
nutritional intake and increased renal excretion.
Question 3
The nurse is providing care to a client who is comatose following cardiac arrest 24 hours
ago. Which physical assessment finding should the nurse determine to be a predictor of
a poor outcome?
A. Lack of response to a sternal rub
B. Lack of corneal or papillary response
C. Lack of purposeful motor response
D. Lack of response to verbal stimulation
Correc Answer:
B. Lack of corneal or papillary response