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Adult Health Exam 1
1. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which
assessment data will be of most concern to the nurse? a. Blood pressure is 90/40 mm Hg. b.
Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d.
There is prolonged skin tenting over the sternum. _ ANS: A The blood pressure indicates that the
patient may be developing hypovolemic shock as a result of intravascular fluid loss due to the
burn injury. This finding will require immediate intervention to prevent the complications
associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin
tenting all indicate the need for increasing the patients fluid intake but not as urgently as the
hypotension.
2. A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate
antidiuretic hormone (SIADH). The nurse should notify the health care provider about which
assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level
of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours _ ANS: C Hyponatremia is
the most important finding to report. SIADH causes water retention and a decrease in serum
sodium level. Hyponatremia can cause confusion and other central nervous system effects. A
critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates
adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH
because of water retention.
3. A patient is admitted for hypovolemia associated with multiple draining wounds. Which
assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin
turgor b. Daily weight c. Presence of edema d. Hourly urine output _ ANS: B Daily weight is the
most easily obtained and accurate means of assessing volume status. Skin turgor varies
considerably with age. Considerable excess fluid volume may be present before fluid moves into
the interstitial space and causes edema. Although very important, hourly urine outputs do not
take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the
gastrointestinal tract or wounds.
Adult Health Exam 1.pdf Adult Health Exam
Adult
1.pdf~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~!!!!!!!!%%%%%%%%%%%%%%%%%%%
Health Exam 1.pdf
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Adult Health Exam Adult1.pdf
Health Exam 1.pdf@@@@@@@@@@@@@@@@!!!!!!!!!!!!!!!!!!!!!!!
4. The home health nurse cares for an alert and oriented older adult patient with a history of
dehydration. Which instructions should the nurse give to this patient related to fluid intake? a.
Increase fluids if your mouth feels dry. b. More fluids are needed if you feel thirsty. c. Drink
more fluids in the late evening hours. d. If you feel lethargic or confused, you need more to
drink. _ ANS: A An alert, older patient will be able to self-assess for signs of oral dryness such
as thick oral secretions or dry- appearing mucosa. The thirst mechanism decreases with age and
is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids
slightly in the evening to improve sleep quality. The patient will not be likely to notice and act
appropriately when changes in level of consciousness occur.
5. A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains
of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for
facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid
orange juice with meals. d. Ask the health care provider to order a basic metabolic panel. _ ANS:
D Generalized weakness is a manifestation of hypokalemia. After the health care provider orders
the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might
occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if
the patient was hypokalemic. Loose stools are associated with hyperkalemia.
6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which
statement by the patient indicates that the teaching about this medication has been effective? a. I
will try to drink at least 8 glasses of water every day. b. I will use a salt substitute to decrease my
sodium intake. c. I will increase my intake of potassium-containing foods. d. I will drink apple
juice instead of orange juice for breakfast _ ANS: D Because spironolactone is a potassium-
sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice)
rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is
using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid
intake. Teach patients to avoid salt substitutes, which are high in potassium.
7. A newly admitted patient is diagnosed with hyponatremia. When making room assignments,
the charge nurse should take which action? a. Assign the patient to a room near the nurses
Adult Health Exam 1.pdf Adult Health Exam
Adult
1.pdf~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~!!!!!!!!%%%%%%%%%%%%%%%%%%%
Health Exam 1.pdf
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Adult Health Exam Adult1.pdf
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station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on
telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place
an order for a low-salt diet. _ ANS: A The patient should be placed near the nurses station if
confused in order for the staff to closely monitor the patient. To help improve serum sodium
levels, water intake is restricted. Therefore a confused patient should not be placed near a water
fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient
could be distracting and disruptive for another patient in a semiprivate room. This patient needs
sodium replacement, not restriction.
8. IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe
hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b.
Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d.
Discontinue cardiac monitoring during the infusion. _ ANS: B IV KCl is administered at a
maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the
preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may
be used for some patients. KCl can cause inflammation of peripheral veins, but it can be
administered by this route. Cardiac monitoring should be continued while patient is receiving
potassium because of the risk for dysrhythmias.
9. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving
nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127
mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at
125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV
metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if
serum sodium decreases to less than 128 mEq/L. _ ANS: A Because the patients gastric suction
has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions
such as lactated Ringers solution would usually be ordered for this patient. The other orders are
appropriate for a postoperative patient with gastric suction.
10. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow
for continued mechanical ventilation. How should the nurse interpret the following arterial blood
Adult Health Exam 1.pdf Adult Health Exam
Adult
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Health Exam 1.pdf
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gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic
acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis _ ANS: D The pH
indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The
other responses are incorrect based on the pH and the normal HCO3 .
11. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep
respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam
(Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed
normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided
imagery _ ANS: C The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the
need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by
insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated
because there is no indication that the increased respiratory rate is related to hypoxemia. The
respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate.
Lorazepam administration will slow the respiratory rate and increase the level of acido
12. An older adult patient who is malnourished presents to the emergency department with a
serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor
b. Edema c. Confusion d. Restlessness _ ANS: B The normal range for total protein is 6.4 to 8.3
g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to
remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not
associated with low serum protein levels.
13. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment
ismost important for the nurse to monitor for while the patient is receiving this infusion? a. Lung
sounds b. Urinary output c. Peripheral pulses d. Peripheral edema _ ANS: A Hypertonic
solutions cause water retention, so the patient should be monitored for symptoms of fluid excess.
Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation
of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are
also important to monitor when administering hypertonic solutions, but they do not indicate
acute respiratory or cardiac decompensation.
Adult Health Exam 1.pdf Adult Health Exam
Adult
1.pdf~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~!!!!!!!!%%%%%%%%%%%%%%%%%%%
Health Exam 1.pdf
Adult Health Exam Adult1.pdf
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Adult Health Exam 1
1. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which
assessment data will be of most concern to the nurse? a. Blood pressure is 90/40 mm Hg. b.
Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d.
There is prolonged skin tenting over the sternum. _ ANS: A The blood pressure indicates that the
patient may be developing hypovolemic shock as a result of intravascular fluid loss due to the
burn injury. This finding will require immediate intervention to prevent the complications
associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin
tenting all indicate the need for increasing the patients fluid intake but not as urgently as the
hypotension.
2. A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate
antidiuretic hormone (SIADH). The nurse should notify the health care provider about which
assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level
of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours _ ANS: C Hyponatremia is
the most important finding to report. SIADH causes water retention and a decrease in serum
sodium level. Hyponatremia can cause confusion and other central nervous system effects. A
critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates
adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH
because of water retention.
3. A patient is admitted for hypovolemia associated with multiple draining wounds. Which
assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin
turgor b. Daily weight c. Presence of edema d. Hourly urine output _ ANS: B Daily weight is the
most easily obtained and accurate means of assessing volume status. Skin turgor varies
considerably with age. Considerable excess fluid volume may be present before fluid moves into
the interstitial space and causes edema. Although very important, hourly urine outputs do not
take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the
gastrointestinal tract or wounds.
Adult Health Exam 1.pdf Adult Health Exam
Adult
1.pdf~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~!!!!!!!!%%%%%%%%%%%%%%%%%%%
Health Exam 1.pdf
,Adult Health Exam 1.pdf@@@@@@@@@@@@@@@@!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Adult Health Exam Adult1.pdf
Health Exam 1.pdf@@@@@@@@@@@@@@@@!!!!!!!!!!!!!!!!!!!!!!!
4. The home health nurse cares for an alert and oriented older adult patient with a history of
dehydration. Which instructions should the nurse give to this patient related to fluid intake? a.
Increase fluids if your mouth feels dry. b. More fluids are needed if you feel thirsty. c. Drink
more fluids in the late evening hours. d. If you feel lethargic or confused, you need more to
drink. _ ANS: A An alert, older patient will be able to self-assess for signs of oral dryness such
as thick oral secretions or dry- appearing mucosa. The thirst mechanism decreases with age and
is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids
slightly in the evening to improve sleep quality. The patient will not be likely to notice and act
appropriately when changes in level of consciousness occur.
5. A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains
of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for
facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid
orange juice with meals. d. Ask the health care provider to order a basic metabolic panel. _ ANS:
D Generalized weakness is a manifestation of hypokalemia. After the health care provider orders
the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might
occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if
the patient was hypokalemic. Loose stools are associated with hyperkalemia.
6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which
statement by the patient indicates that the teaching about this medication has been effective? a. I
will try to drink at least 8 glasses of water every day. b. I will use a salt substitute to decrease my
sodium intake. c. I will increase my intake of potassium-containing foods. d. I will drink apple
juice instead of orange juice for breakfast _ ANS: D Because spironolactone is a potassium-
sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice)
rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is
using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid
intake. Teach patients to avoid salt substitutes, which are high in potassium.
7. A newly admitted patient is diagnosed with hyponatremia. When making room assignments,
the charge nurse should take which action? a. Assign the patient to a room near the nurses
Adult Health Exam 1.pdf Adult Health Exam
Adult
1.pdf~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~!!!!!!!!%%%%%%%%%%%%%%%%%%%
Health Exam 1.pdf
,Adult Health Exam 1.pdf@@@@@@@@@@@@@@@@!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Adult Health Exam Adult1.pdf
Health Exam 1.pdf@@@@@@@@@@@@@@@@!!!!!!!!!!!!!!!!!!!!!!!
station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on
telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place
an order for a low-salt diet. _ ANS: A The patient should be placed near the nurses station if
confused in order for the staff to closely monitor the patient. To help improve serum sodium
levels, water intake is restricted. Therefore a confused patient should not be placed near a water
fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient
could be distracting and disruptive for another patient in a semiprivate room. This patient needs
sodium replacement, not restriction.
8. IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe
hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b.
Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d.
Discontinue cardiac monitoring during the infusion. _ ANS: B IV KCl is administered at a
maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the
preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may
be used for some patients. KCl can cause inflammation of peripheral veins, but it can be
administered by this route. Cardiac monitoring should be continued while patient is receiving
potassium because of the risk for dysrhythmias.
9. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving
nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127
mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at
125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV
metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if
serum sodium decreases to less than 128 mEq/L. _ ANS: A Because the patients gastric suction
has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions
such as lactated Ringers solution would usually be ordered for this patient. The other orders are
appropriate for a postoperative patient with gastric suction.
10. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow
for continued mechanical ventilation. How should the nurse interpret the following arterial blood
Adult Health Exam 1.pdf Adult Health Exam
Adult
1.pdf~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~!!!!!!!!%%%%%%%%%%%%%%%%%%%
Health Exam 1.pdf
, Adult Health Exam 1.pdf@@@@@@@@@@@@@@@@!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Adult Health Exam Adult1.pdf
Health Exam 1.pdf@@@@@@@@@@@@@@@@!!!!!!!!!!!!!!!!!!!!!!!
gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic
acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis _ ANS: D The pH
indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The
other responses are incorrect based on the pH and the normal HCO3 .
11. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep
respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam
(Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed
normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided
imagery _ ANS: C The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the
need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by
insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated
because there is no indication that the increased respiratory rate is related to hypoxemia. The
respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate.
Lorazepam administration will slow the respiratory rate and increase the level of acido
12. An older adult patient who is malnourished presents to the emergency department with a
serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor
b. Edema c. Confusion d. Restlessness _ ANS: B The normal range for total protein is 6.4 to 8.3
g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to
remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not
associated with low serum protein levels.
13. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment
ismost important for the nurse to monitor for while the patient is receiving this infusion? a. Lung
sounds b. Urinary output c. Peripheral pulses d. Peripheral edema _ ANS: A Hypertonic
solutions cause water retention, so the patient should be monitored for symptoms of fluid excess.
Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation
of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are
also important to monitor when administering hypertonic solutions, but they do not indicate
acute respiratory or cardiac decompensation.
Adult Health Exam 1.pdf Adult Health Exam
Adult
1.pdf~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~!!!!!!!!%%%%%%%%%%%%%%%%%%%
Health Exam 1.pdf
