2
Adult Health III Final Exam with verified detailed answers
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The nurse is caring for a patient who has septic shock. Which assessment finding is most
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important for the nurse to report to the health care provider?
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a. skin cool and clammy
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b. heart rate of 118 beats/min
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c. blood pressure of 92/56
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d. O2 saturation of 93% on room air - ✔✔Answer: a
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Which assessment finding by the nurse caring for a patient receiving mechanical ventilation
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indicates the need for suctioning?
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a. the patient's respiratory rate is 32 breaths/min
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b. the patient has occasional audible expiratory wheezes
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c. the patient's oxygen saturation drops to 93%
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d. the patient was last suctioned 6 hours ago - ✔✔Answer: a
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The nurse in the emergency department is caring for a client with a history of smoking who
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is obese and admitted with epigastric pain. The client is diagnosed with abdominal aortic
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aneurysm after having an X-ray. During assessment the nurse notes ecchymosis to the
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client's back side. Which of the following actions would be priority for the nurse to take?
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a. prepare the client for a blood transfusion
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b. obtain informed consent for emergency surgery
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c. obtain the client's blood pressure
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d. assess the client's lung sounds - ✔✔Answer: b
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,2
The nurse is caring for a client who is experiencing neurogenic shock after a spinal cord
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injury. The nurse has taught the client's spouse about neurogenic shock. Which of the
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following statements by the client's spouse requires follow-up?
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a. this type of shock causes excessive urine loss
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b. my spouse may have difficulty maintaining normal body temperature
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c. this type of shock causes the heart rate to be too low
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d. my spouse is receiving medicine to keep the blood pressure high enough - ✔✔Answer: a
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The nurse is caring for a client who was exposed to inhalation anthrax and is to receive
|| || || || || || || || || || || || || || || || ||
prescribed ciprofloxacin 800mg, once per day, IV for 60 days. The nurse has 800mg/250mL
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in D5W to be infused over 2 hours. How many mL per hour should the nurse administer?
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Do not round your answer. Enter numeric value only. - ✔✔Answer: 125
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A nurse is caring for a client experiencing atrial flutter in the telemetry monitor. Which of
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the following characteristics and manifestations should the nurse expect to see? Select all
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that apply. ||
a. shortened PR interval
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b. Hypertension
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c. an irregular atrial rate that is between 350 and 600 beats/min
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d. Normal QRS complex
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e. Alcohol intoxication
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f. a regular ventricular rate that is greater than or less than 100 beats/min - ✔✔Answer: a, c,
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f
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The nurse is assessing a client with a head injury who is exhibiting an altered level of
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consciousness (LOC) and had clear fluid leaking from the right ear. Which of the following || || || || || || || || || || || || || || ||
actions would be priority for the nurse to take? || || || || || || || ||
a. prepare the client for surgery
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b. monitor the client for increased intercranial pressure (ICP)
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, 2
c. insert a peripheral intravenous catheter
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d. provide seizure precautions - ✔✔Answer: b
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Which patient is most appropriate for the burn unit charge nurse to assign to a registered
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nurse (RN) who has floated from the hospital medical unit?
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a. a patient who has twice-daily burn debridements to partial-thickness facial burns
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b. a patient who just returned from having a cultured epithelial autograft to the chest
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c. a patient who has blebs under an autograft on the thigh and has an order for bleb
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aspiration
d. a patient who has a 15% body weight loss from admission and will need enteral feedings -
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✔✔Answer: d
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A patient arrives in the emergency department with facial and chest burns caused by a
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house fire. Which action should the nurse take first?
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a. give the prescribed hydromorphone (Dilaudid)
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b. auscultate for breath sounds
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c. determine the extent and depth of the burns resuscitative
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infuse the prescribed lactated ringer's solution - ✔✔Answer: b
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The nurse is planning an education conference about calculating the client's heart rate
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forma telemetry strip. Which of the following information should the nurse include in the
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conference? Select all that apply. || || || ||
a. count the number of QRS complexes seen in one minute
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b. count the number of large squares between an R to R interval and divide the number into
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300
||
c. count the number of small squares between the R to R interval and divide the number
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into 1500 ||
d. count the number of P to P intervals in 6 seconds and multiply that number by 10
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Adult Health III Final Exam with verified detailed answers
|| || || || || || || ||
The nurse is caring for a patient who has septic shock. Which assessment finding is most
|| || || || || || || || || || || || || || || ||
important for the nurse to report to the health care provider?
|| || || || || || || || || ||
a. skin cool and clammy
|| || || ||
b. heart rate of 118 beats/min
|| || || || ||
c. blood pressure of 92/56
|| || || ||
d. O2 saturation of 93% on room air - ✔✔Answer: a
|| || || || || || || || || ||
Which assessment finding by the nurse caring for a patient receiving mechanical ventilation
|| || || || || || || || || || || ||
indicates the need for suctioning?
|| || || || ||
a. the patient's respiratory rate is 32 breaths/min
|| || || || || || ||
b. the patient has occasional audible expiratory wheezes
|| || || || || || ||
c. the patient's oxygen saturation drops to 93%
|| || || || || || ||
d. the patient was last suctioned 6 hours ago - ✔✔Answer: a
|| || || || || || || || || || ||
The nurse in the emergency department is caring for a client with a history of smoking who
|| || || || || || || || || || || || || || || ||
is obese and admitted with epigastric pain. The client is diagnosed with abdominal aortic
|| || || || || || || || || || || || || || ||
aneurysm after having an X-ray. During assessment the nurse notes ecchymosis to the
|| || || || || || || || || || || || ||
client's back side. Which of the following actions would be priority for the nurse to take?
|| || || || || || || || || || || || || || ||
a. prepare the client for a blood transfusion
|| || || || || || ||
b. obtain informed consent for emergency surgery
|| || || || || ||
c. obtain the client's blood pressure
|| || || || ||
d. assess the client's lung sounds - ✔✔Answer: b
|| || || || || || || ||
,2
The nurse is caring for a client who is experiencing neurogenic shock after a spinal cord
|| || || || || || || || || || || || || || || ||
injury. The nurse has taught the client's spouse about neurogenic shock. Which of the
|| || || || || || || || || || || || || ||
following statements by the client's spouse requires follow-up?
|| || || || || || ||
a. this type of shock causes excessive urine loss
|| || || || || || || ||
b. my spouse may have difficulty maintaining normal body temperature
|| || || || || || || || ||
c. this type of shock causes the heart rate to be too low
|| || || || || || || || || || || ||
d. my spouse is receiving medicine to keep the blood pressure high enough - ✔✔Answer: a
|| || || || || || || || || || || || || || ||
The nurse is caring for a client who was exposed to inhalation anthrax and is to receive
|| || || || || || || || || || || || || || || || ||
prescribed ciprofloxacin 800mg, once per day, IV for 60 days. The nurse has 800mg/250mL
|| || || || || || || || || || || || || ||
in D5W to be infused over 2 hours. How many mL per hour should the nurse administer?
|| || || || || || || || || || || || || || || || ||
Do not round your answer. Enter numeric value only. - ✔✔Answer: 125
|| || || || || || || || || || ||
A nurse is caring for a client experiencing atrial flutter in the telemetry monitor. Which of
|| || || || || || || || || || || || || || || ||
the following characteristics and manifestations should the nurse expect to see? Select all
|| || || || || || || || || || || || ||
that apply. ||
a. shortened PR interval
|| || ||
b. Hypertension
||
c. an irregular atrial rate that is between 350 and 600 beats/min
|| || || || || || || || || || ||
d. Normal QRS complex
|| || ||
e. Alcohol intoxication
|| ||
f. a regular ventricular rate that is greater than or less than 100 beats/min - ✔✔Answer: a, c,
|| || || || || || || || || || || || || || || || ||
f
||
The nurse is assessing a client with a head injury who is exhibiting an altered level of
|| || || || || || || || || || || || || || || || ||
consciousness (LOC) and had clear fluid leaking from the right ear. Which of the following || || || || || || || || || || || || || || ||
actions would be priority for the nurse to take? || || || || || || || ||
a. prepare the client for surgery
|| || || || ||
b. monitor the client for increased intercranial pressure (ICP)
|| || || || || || || ||
, 2
c. insert a peripheral intravenous catheter
|| || || || ||
d. provide seizure precautions - ✔✔Answer: b
|| || || || || ||
Which patient is most appropriate for the burn unit charge nurse to assign to a registered
|| || || || || || || || || || || || || || || ||
nurse (RN) who has floated from the hospital medical unit?
|| || || || || || || || ||
a. a patient who has twice-daily burn debridements to partial-thickness facial burns
|| || || || || || || || || || ||
b. a patient who just returned from having a cultured epithelial autograft to the chest
|| || || || || || || || || || || || || ||
c. a patient who has blebs under an autograft on the thigh and has an order for bleb
|| || || || || || || || || || || || || || || || || ||
aspiration
d. a patient who has a 15% body weight loss from admission and will need enteral feedings -
|| || || || || || || || || || || || || || || || ||
✔✔Answer: d
|| ||
A patient arrives in the emergency department with facial and chest burns caused by a
|| || || || || || || || || || || || || || ||
house fire. Which action should the nurse take first?
|| || || || || || || ||
a. give the prescribed hydromorphone (Dilaudid)
|| || || || ||
b. auscultate for breath sounds
|| || || ||
c. determine the extent and depth of the burns resuscitative
|| || || || || || || || ||
infuse the prescribed lactated ringer's solution - ✔✔Answer: b
|| || || || || || || ||
The nurse is planning an education conference about calculating the client's heart rate
|| || || || || || || || || || || || ||
forma telemetry strip. Which of the following information should the nurse include in the
|| || || || || || || || || || || || || ||
conference? Select all that apply. || || || ||
a. count the number of QRS complexes seen in one minute
|| || || || || || || || || ||
b. count the number of large squares between an R to R interval and divide the number into
|| || || || || || || || || || || || || || || || ||
300
||
c. count the number of small squares between the R to R interval and divide the number
|| || || || || || || || || || || || || || || || ||
into 1500 ||
d. count the number of P to P intervals in 6 seconds and multiply that number by 10
|| || || || || || || || || || || || || || || || ||
