Focus On Adult Health
Exam WITH CORRECT
ANSWERS 2025/2026
A client arrives at the emergency department and reports a
buzzing sound in his ear. The client tells the nurse that an insect
flew into the ear. Which intervention does the nurse take first to
remove the insect? - correct answer -Instilling lidocaine into the
ear
Rationale: Insects that make their way into an ear are killed
before removal unless they can be coaxed out with the use of a
flashlight or a humming noise. Mineral oil, diluted alcohol, or
lidocaine (not water) is instilled into the ear canal (or an ether-
soaked cotton ball is placed in the ear) to suffocate the insect,
which is then removed with the use of ear forceps. When the
foreign object is vegetable matter, irrigation is not used, because
this material expands with hydration, worsening the impaction
becomes worse. Antibiotics may or may not be prescribed after
removal of the insect.
, A client arrives in the emergency department after sustaining a
chemical splash to the eye. The nurse immediately flushes the eye
with copious amounts of normal saline solution for 15 minutes
and then tests the pH of eye, using litmus paper. The nurse should
continue the saline flushes until the pH test reads: - correct
answer-7.40
Rationale: First aid after a chemical burn to the eye consists of
irrigation of the eye with copious amounts of tap water for at
least 5 minutes. As soon as the initial irrigation is complete, the
victim should be rushed to the nearest medical facility. On arrival,
eye irrigation should be resumed with water or normal saline for
15 to 20 minutes or until all invasive material is gone and litmus
paper reveals a pH of about 7.40. A quick test with litmus can be
performed before, during, and after irrigations to determine the
pH and to ascertain whether the substance was acid or alkaline.
The normal body pH is 7.40.
A client complains of a rapid heartbeat and shortness of breath.
While watching the client's cardiac monitor, the nurse notes the
following pattern:
The nurse interprets this finding as: - correct answerAtrial
fibrillation
Rationale: Atrial fibrillation is a dysrhythmia arising when ectopic
foci in the atrium discharge impulses at a rate of 400 beats/min or
faster. There are usually no definable P waves; these impulses are
so rapid that they cause the atria to quiver instead of contracting
regularly, producing irregular wavy deflections. Because
ventricular depolarization is fairly normal in atrial fibrillation, the
QRS complexes appear normal. Atrial flutter is marked by the
"sawtooth" appearance of P waves that may or may not be
, regular. Ventricular fibrillation and ventricular tachycardia do not
feature normal QRS complexes.
A client has a prescription to have blood drawn from the radial
artery for a set of arterial blood gas (ABG) determinations. For
which test does the nurse look for a positive result before the
blood is drawn? - correct answerAllen test
Rationale: The Allen test is performed before blood is drawn for
assessment of arterial blood gases. The radial and ulnar arteries
are occluded in turn, then released, after which the distal
circulation is assessed. If the result is positive, the client has
adequate circulation and that site may be used. The Trousseau
sign is an indication of the presence of carpopedal spasms,
denoting hypocalcemia. The presence of the Brudzinski sign
indicates nuchal rigidity. The Babinski reflex is used to assess
neurological dysfunction.
A client has been taking pyrazinamide (PMS Pyrazinamide) for 2
months. Which culture result does the nurse monitor as an
indicator that the medication may soon be discontinued? - correct
answerSputum
Rationale: Pyrazinamide is an antitubercular medication that is
given in conjunction with other antitubercular medications. The
prescriber may discontinue its use if sputum cultures become
negative. Urine, blood, and wound cultures are not associated
with the use of this medication.
A client hospitalized with an abdominal aortic aneurysm (AAA)
suddenly complains of severe back and flank pain. The nurse
notes on the cardiac monitor that the client's heart rate has
, increased from 80 to 110 beats/min. The nurse should: - correct
answerImmediately contact the health care provider
Rationale: The signs and symptoms in the question are indicative
of rupture of the AAA. Typical signs and symptoms of rupture
include back and flank pain, ecchymosis of the flank and perianal
areas, a pulsating abdominal mass, lightheadedness, nausea, and
signs of shock. This is an emergency situation, and the client
requires simultaneous resuscitation and preparation for
immediate surgical repair. The other options are incorrect and
would delay necessary treatment.
A client infected with HIV has a T4 count of 150/mm3 and a low
CD4+/CD8+ ratio. On the basis of these values, the nurse
concludes that the client is: - correct answerA risk for
opportunistic infection
Rationale: The percentage and number of CD4+ (T4) and CD8+
(T8) cells are an important part of an immune profile. Individuals
with HIV disease usually have a lower-than-normal number of CD4
cells. The normal CD4+ count is between 500 and 1600 cells/mm3.
The normal ratio of CD4+ to CD8+ cells is approximately 2:1. In
HIV infection, because of the low number of CD4+ cells, this ratio
is low. A low CD4+ cell count and a low CD4+/CD8+ ratio are
associated with increased incidence of clinical manifestations of
the disease, and the client is at risk for opportunistic infection.
The nurse uses this information in planning infection-control
measures for the client. The remaining options are incorrect
interpretations.
A client is experiencing frequent premature ventricular
contractions (PVCs). To which assessment would the nurse give
priority? - correct answerPeripheral perfusion
Exam WITH CORRECT
ANSWERS 2025/2026
A client arrives at the emergency department and reports a
buzzing sound in his ear. The client tells the nurse that an insect
flew into the ear. Which intervention does the nurse take first to
remove the insect? - correct answer -Instilling lidocaine into the
ear
Rationale: Insects that make their way into an ear are killed
before removal unless they can be coaxed out with the use of a
flashlight or a humming noise. Mineral oil, diluted alcohol, or
lidocaine (not water) is instilled into the ear canal (or an ether-
soaked cotton ball is placed in the ear) to suffocate the insect,
which is then removed with the use of ear forceps. When the
foreign object is vegetable matter, irrigation is not used, because
this material expands with hydration, worsening the impaction
becomes worse. Antibiotics may or may not be prescribed after
removal of the insect.
, A client arrives in the emergency department after sustaining a
chemical splash to the eye. The nurse immediately flushes the eye
with copious amounts of normal saline solution for 15 minutes
and then tests the pH of eye, using litmus paper. The nurse should
continue the saline flushes until the pH test reads: - correct
answer-7.40
Rationale: First aid after a chemical burn to the eye consists of
irrigation of the eye with copious amounts of tap water for at
least 5 minutes. As soon as the initial irrigation is complete, the
victim should be rushed to the nearest medical facility. On arrival,
eye irrigation should be resumed with water or normal saline for
15 to 20 minutes or until all invasive material is gone and litmus
paper reveals a pH of about 7.40. A quick test with litmus can be
performed before, during, and after irrigations to determine the
pH and to ascertain whether the substance was acid or alkaline.
The normal body pH is 7.40.
A client complains of a rapid heartbeat and shortness of breath.
While watching the client's cardiac monitor, the nurse notes the
following pattern:
The nurse interprets this finding as: - correct answerAtrial
fibrillation
Rationale: Atrial fibrillation is a dysrhythmia arising when ectopic
foci in the atrium discharge impulses at a rate of 400 beats/min or
faster. There are usually no definable P waves; these impulses are
so rapid that they cause the atria to quiver instead of contracting
regularly, producing irregular wavy deflections. Because
ventricular depolarization is fairly normal in atrial fibrillation, the
QRS complexes appear normal. Atrial flutter is marked by the
"sawtooth" appearance of P waves that may or may not be
, regular. Ventricular fibrillation and ventricular tachycardia do not
feature normal QRS complexes.
A client has a prescription to have blood drawn from the radial
artery for a set of arterial blood gas (ABG) determinations. For
which test does the nurse look for a positive result before the
blood is drawn? - correct answerAllen test
Rationale: The Allen test is performed before blood is drawn for
assessment of arterial blood gases. The radial and ulnar arteries
are occluded in turn, then released, after which the distal
circulation is assessed. If the result is positive, the client has
adequate circulation and that site may be used. The Trousseau
sign is an indication of the presence of carpopedal spasms,
denoting hypocalcemia. The presence of the Brudzinski sign
indicates nuchal rigidity. The Babinski reflex is used to assess
neurological dysfunction.
A client has been taking pyrazinamide (PMS Pyrazinamide) for 2
months. Which culture result does the nurse monitor as an
indicator that the medication may soon be discontinued? - correct
answerSputum
Rationale: Pyrazinamide is an antitubercular medication that is
given in conjunction with other antitubercular medications. The
prescriber may discontinue its use if sputum cultures become
negative. Urine, blood, and wound cultures are not associated
with the use of this medication.
A client hospitalized with an abdominal aortic aneurysm (AAA)
suddenly complains of severe back and flank pain. The nurse
notes on the cardiac monitor that the client's heart rate has
, increased from 80 to 110 beats/min. The nurse should: - correct
answerImmediately contact the health care provider
Rationale: The signs and symptoms in the question are indicative
of rupture of the AAA. Typical signs and symptoms of rupture
include back and flank pain, ecchymosis of the flank and perianal
areas, a pulsating abdominal mass, lightheadedness, nausea, and
signs of shock. This is an emergency situation, and the client
requires simultaneous resuscitation and preparation for
immediate surgical repair. The other options are incorrect and
would delay necessary treatment.
A client infected with HIV has a T4 count of 150/mm3 and a low
CD4+/CD8+ ratio. On the basis of these values, the nurse
concludes that the client is: - correct answerA risk for
opportunistic infection
Rationale: The percentage and number of CD4+ (T4) and CD8+
(T8) cells are an important part of an immune profile. Individuals
with HIV disease usually have a lower-than-normal number of CD4
cells. The normal CD4+ count is between 500 and 1600 cells/mm3.
The normal ratio of CD4+ to CD8+ cells is approximately 2:1. In
HIV infection, because of the low number of CD4+ cells, this ratio
is low. A low CD4+ cell count and a low CD4+/CD8+ ratio are
associated with increased incidence of clinical manifestations of
the disease, and the client is at risk for opportunistic infection.
The nurse uses this information in planning infection-control
measures for the client. The remaining options are incorrect
interpretations.
A client is experiencing frequent premature ventricular
contractions (PVCs). To which assessment would the nurse give
priority? - correct answerPeripheral perfusion
