ADULT HEALTH NR 325 FINAL EXAM QUESTIONS
AND ANSWERS
When examining an older patient in the home, the home health nurse notices
irregular patterns of bruising at different stages of healing on the patient's body.
Which action should the nurse take first? - ANSWER -talk with the patient alone
and ask about what caused the bruising
The nurse assess a circular, flat, reddened lesion about 5 cm in diameter on a
middle-aged patient's ankle. How should the nurse determine if the lesion is related
to intradermal bleeding - ANSWER -Press firmly on the lesion
Which integumentary assessment data from an older patient admitted with
bacterial pneumonia is of most concern for the nurse? - ANSWER -Reports a
history of allergic rashes
When taking the health history of an older adult, the nurse discovers that the
patient has worked in the landscaping business for 40 years. The nurse will plan to
teach the patient about how to self-assess for which clinical manifestations? -
ANSWER -actinic keratosis and erythema
A patient who is scheduled for a right breast biopsy asks the nurse the difference
between a benign tumor and a malignant tumor. Which ANSWER by the nurse is
correct? - ANSWER -"Malignant tumors may spread to other tissues or organs"
A nurse is caring for a patient who smokes 2 packs/day. To reduce the patient's
risk of lung cancer, which action by the nurse is the best? - ANSWER -Discuss the
risks associated with cigarettes during every patient encounter
The nurse should include which food choice when providing dietary teaching for a
patient scheduled to receive external beam radiation for abdominal cancer? -
ANSWER -Roasted chicken
, A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0
asks the nurse what the letters and numbers mean. Which response by the nurse is
most appropriate? - ANSWER -"the cancer involves only the cervix"
During the teaching session for a patient who has a new diagnosis of acute
leukemia the patient is restless and is looking away, never making eye contact.
After teaching about the complications associated with chemotherapy, the patient
asks the nurse to repeat all of the information. Based on this assessment, which
nursing diagnosis is most appropriate for the patient? - ANSWER -Risk for
ineffective health maintenance related to anxiety about new leukemia
A hospitalized patient who has received chemotherapy for leukemia develops
neutropenia. Which observation by the nurse would indicate a need for further
teaching - ANSWER -The patients visitors bring in some fresh peaches from home
The nurse receives change-of-shift report on the oncology unit. Which patient
should the nurse assess first? - ANSWER -24-year-old patient who received neck
radiation and has blood oozing from the neck
An older adult patient who has colorectal cancer is receiving IV fluids at
175mL/hour in conjunction with the prescribed chemotherapy. Which finding by
the nurse is most important to report to the health care provider? - ANSWER -
Patient has audible crackles in the midline posterior chest
A patient with an open leg wound has a white blood cell (WBC) count of
13,500/uL and a band count of 11%. Which action should the nurse take first? -
ANSWER -Obtain wound cultures
A patient has an open surgical wound on the abdomen that contains deep pink
granulation tissue. How would the nurse document this wound? - ANSWER -Red
wound
A patient from a long-term care facility is admitted to the hospital with a sacral
pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue.
How should the nurse classify this pressure ulcer? - ANSWER -Stage III
, A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is
being cared for at home by his mother. To prevent further tissue damage, what
instructions are most important for the nurse to teach the mother? - ANSWER -
Change the patient's position at least every 2 hours
A new nurse performs a dressing change on a stage II left heel pressure ulcer.
Which action by the new nurse indicates a need for further teaching about pressure
ulcer care? - ANSWER -the new nurse cleans the ulcer with a sterile dressing
soaked in half-strength peroxide
Which finding is most important for the nurse to communicate to the health care
provider when caring for a patient who is receiving negative pressure wound
therapy? - ANSWER -Low serum albumin level
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days
ago. Which finding is most important for the nurse to report to the health care
provider? - ANSWER -Separation of the proximal wound edges by 1 cm
After receiving a change-of-shift report, which patient should the nurse assess
first? - ANSWER -The patient who has been receiving chemotherapy and has a
temperature of 102 F
A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that i
will die in surgery like my mother did." Which response by the nurse is most
appropriate? - ANSWER -"Tell me more about what happened to your mother"
A 38-year-old female is admitted for an elective surgical procedure. Which
information obtained by the nurse during the preoperative assessment is most
important to report to the anesthesiologist before surgery? - ANSWER -The
patient's statement that her last menstrual period was 8 weeks previously
The nurse is preparing to witness the patient signing the operative consent form
when the patient says, "I do not really understand what the doctor said," which
AND ANSWERS
When examining an older patient in the home, the home health nurse notices
irregular patterns of bruising at different stages of healing on the patient's body.
Which action should the nurse take first? - ANSWER -talk with the patient alone
and ask about what caused the bruising
The nurse assess a circular, flat, reddened lesion about 5 cm in diameter on a
middle-aged patient's ankle. How should the nurse determine if the lesion is related
to intradermal bleeding - ANSWER -Press firmly on the lesion
Which integumentary assessment data from an older patient admitted with
bacterial pneumonia is of most concern for the nurse? - ANSWER -Reports a
history of allergic rashes
When taking the health history of an older adult, the nurse discovers that the
patient has worked in the landscaping business for 40 years. The nurse will plan to
teach the patient about how to self-assess for which clinical manifestations? -
ANSWER -actinic keratosis and erythema
A patient who is scheduled for a right breast biopsy asks the nurse the difference
between a benign tumor and a malignant tumor. Which ANSWER by the nurse is
correct? - ANSWER -"Malignant tumors may spread to other tissues or organs"
A nurse is caring for a patient who smokes 2 packs/day. To reduce the patient's
risk of lung cancer, which action by the nurse is the best? - ANSWER -Discuss the
risks associated with cigarettes during every patient encounter
The nurse should include which food choice when providing dietary teaching for a
patient scheduled to receive external beam radiation for abdominal cancer? -
ANSWER -Roasted chicken
, A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0
asks the nurse what the letters and numbers mean. Which response by the nurse is
most appropriate? - ANSWER -"the cancer involves only the cervix"
During the teaching session for a patient who has a new diagnosis of acute
leukemia the patient is restless and is looking away, never making eye contact.
After teaching about the complications associated with chemotherapy, the patient
asks the nurse to repeat all of the information. Based on this assessment, which
nursing diagnosis is most appropriate for the patient? - ANSWER -Risk for
ineffective health maintenance related to anxiety about new leukemia
A hospitalized patient who has received chemotherapy for leukemia develops
neutropenia. Which observation by the nurse would indicate a need for further
teaching - ANSWER -The patients visitors bring in some fresh peaches from home
The nurse receives change-of-shift report on the oncology unit. Which patient
should the nurse assess first? - ANSWER -24-year-old patient who received neck
radiation and has blood oozing from the neck
An older adult patient who has colorectal cancer is receiving IV fluids at
175mL/hour in conjunction with the prescribed chemotherapy. Which finding by
the nurse is most important to report to the health care provider? - ANSWER -
Patient has audible crackles in the midline posterior chest
A patient with an open leg wound has a white blood cell (WBC) count of
13,500/uL and a band count of 11%. Which action should the nurse take first? -
ANSWER -Obtain wound cultures
A patient has an open surgical wound on the abdomen that contains deep pink
granulation tissue. How would the nurse document this wound? - ANSWER -Red
wound
A patient from a long-term care facility is admitted to the hospital with a sacral
pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue.
How should the nurse classify this pressure ulcer? - ANSWER -Stage III
, A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is
being cared for at home by his mother. To prevent further tissue damage, what
instructions are most important for the nurse to teach the mother? - ANSWER -
Change the patient's position at least every 2 hours
A new nurse performs a dressing change on a stage II left heel pressure ulcer.
Which action by the new nurse indicates a need for further teaching about pressure
ulcer care? - ANSWER -the new nurse cleans the ulcer with a sterile dressing
soaked in half-strength peroxide
Which finding is most important for the nurse to communicate to the health care
provider when caring for a patient who is receiving negative pressure wound
therapy? - ANSWER -Low serum albumin level
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days
ago. Which finding is most important for the nurse to report to the health care
provider? - ANSWER -Separation of the proximal wound edges by 1 cm
After receiving a change-of-shift report, which patient should the nurse assess
first? - ANSWER -The patient who has been receiving chemotherapy and has a
temperature of 102 F
A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that i
will die in surgery like my mother did." Which response by the nurse is most
appropriate? - ANSWER -"Tell me more about what happened to your mother"
A 38-year-old female is admitted for an elective surgical procedure. Which
information obtained by the nurse during the preoperative assessment is most
important to report to the anesthesiologist before surgery? - ANSWER -The
patient's statement that her last menstrual period was 8 weeks previously
The nurse is preparing to witness the patient signing the operative consent form
when the patient says, "I do not really understand what the doctor said," which
