NUR 111 – Nursing Care of Adults I Adult
Patient Care Study Guide, Medical-Surgical
Nursing, Clinical Practice, Disease
Management, and Comprehensive Review
Q1. A nurse is caring for a patient with newly diagnosed hypertension. Which of
the following is the priority nursing intervention?
A) Administer antihypertensive medication as prescribed
B) Provide patient education on lifestyle modifications and medication
adherence
C) Obtain a baseline electrocardiogram (ECG)
D) Restrict the patient's fluid intake
Answer: B — Provide patient education on lifestyle modifications and
medication adherence
Rationale: The priority nursing intervention for a patient with newly diagnosed
hypertension is patient education on lifestyle modifications (dietary changes,
weight management, exercise, smoking cessation) and medication adherence.
Hypertension is a chronic condition that requires ongoing management. While
medication administration and diagnostic testing are important, education is the
foundation for long-term management and prevention of complications. Patient
education empowers the patient to take an active role in their care.
Q2. A nurse is assessing a patient who is 24 hours post-operative following
abdominal surgery. The patient reports a pain level of 6/10. Which of the following
is the most appropriate nursing action?
A) Administer the prescribed analgesic immediately
B) Assess the patient's pain using a standardized pain scale and administer
the prescribed analgesic
C) Encourage the patient to use non-pharmacological pain management techniques
D) Document the pain level and reassess in 4 hours
,Answer: B — Assess the patient's pain using a standardized pain scale and
administer the prescribed analgesic
Rationale: Pain assessment should be performed using a standardized pain scale
(e.g., numeric rating scale, Wong-Baker FACES scale). The nurse should assess
the pain and administer the prescribed analgesic as ordered. Pain is the fifth
vital sign and should be assessed regularly. Non-pharmacological interventions can
be used as adjuncts, but pharmacological intervention is needed for moderate to
severe pain (6/10). Reassessment is essential to evaluate the effectiveness of the
intervention.
Q3. A nurse is preparing to perform a sterile dressing change for a patient with a
surgical wound. Which of the following is a key principle of sterile technique?
A) The sterile field may be left unattended
B) Sterile items should only be touched by other sterile items
C) The edges of the sterile field are considered sterile
D) Sterile gloves may be touched by unsterile hands
Answer: B — Sterile items should only be touched by other sterile items
Rationale: Key principles of sterile technique include: sterile items should only
be touched by other sterile items, the sterile field must be kept within the nurse's
line of sight and above waist level, the edges of the sterile field are considered
contaminated (1-inch border), and once the sterile field is set up, it should not be
left unattended. Sterile gloves should only be touched by other sterile gloves.
Contamination of the sterile field requires re-establishment of the field.
Q4. A nurse is assessing a patient's pain using the PQRST mnemonic. What does
the "Q" in PQRST stand for?
A) Quantity
B) Quality
C) Quick
D) Question
Answer: B — Quality
,Rationale: The PQRST mnemonic is used for pain
assessment: P (Provocation/Palliation), Q (Quality), R (Radiation/Region), S (Seve
rity), and T (Timing). The "Q" assesses the quality of the pain (e.g., sharp, dull,
burning, aching, throbbing). This helps differentiate types of pain and identify the
underlying cause. Pain is subjective and requires thorough assessment.
Q5. A nurse is monitoring a patient receiving a blood transfusion. The patient
develops fever, chills, and hypotension. Which of the following is the priority
nursing action?
A) Slow the transfusion rate
B) Stop the transfusion immediately and notify the provider
C) Administer antipyretics
D) Continue the transfusion and monitor the patient
Answer: B — Stop the transfusion immediately and notify the provider
Rationale: The patient is exhibiting signs of a transfusion reaction (acute
hemolytic reaction). The priority is to stop the transfusion immediately, notify
the provider, and maintain the IV line with normal saline. The nurse should
assess the patient's vital signs, monitor for signs of shock, and send the blood
product and patient's blood sample to the laboratory. Transfusion reactions are
medical emergencies. Fever, chills, and hypotension are classic signs of an acute
hemolytic reaction.
Q6. A nurse is assessing a patient's risk for falls. Which of the following
interventions is most appropriate for a patient at high risk for falls?
A) Place all four bed rails up
B) Place the bed in the lowest position and use bed alarms
C) Restrain the patient
D) Dim the lights
Answer: B — Place the bed in the lowest position and use bed alarms
Rationale: For patients at high risk for falls, interventions include: placing the
bed in the lowest position, using bed alarms, ensuring the call light is within
reach, providing non-slip socks, and performing frequent rounding. Physical
, restraints should be avoided unless absolutely necessary and only used with a
provider's order. Placing all four bed rails up is considered a restraint and should be
avoided. Adequate lighting is important for visibility, not dim lighting.
Q7. A nurse is administering a medication via the intramuscular (IM) route. Which
of the following is the correct site for an IM injection in an adult?
A) The vastus lateralis
B) The ventrogluteal site
C) The dorsogluteal site
D) The deltoid
Answer: B — The ventrogluteal site
Rationale: The ventrogluteal site is the preferred site for intramuscular injections
in adults due to its location away from major nerves and blood vessels. The
dorsogluteal site is no longer recommended due to the proximity of the sciatic
nerve. The vastus lateralis is the preferred site for infants and toddlers. The deltoid
is used for smaller volumes (up to 2 mL). The ventrogluteal site is located in the
hip area and is identified by the triangle formed by the anterior superior iliac spine,
the iliac crest, and the greater trochanter.
Q8. A nurse is assessing a patient's fluid status. Which of the following findings
indicates fluid overload?
A) Decreased jugular venous distention
B) Crackles in the lung bases and peripheral edema
C) Increased urine output
D) Dry mucous membranes
Answer: B — Crackles in the lung bases and peripheral edema
Rationale: Fluid overload presents with crackles (pulmonary edema), peripheral
edema, jugular venous distention, weight gain, and shortness of breath.
Decreased urine output, not increased, is seen in fluid overload. Dry mucous
membranes suggest dehydration. Fluid overload is common in patients with heart
failure, renal failure, or excessive IV fluid administration.
Patient Care Study Guide, Medical-Surgical
Nursing, Clinical Practice, Disease
Management, and Comprehensive Review
Q1. A nurse is caring for a patient with newly diagnosed hypertension. Which of
the following is the priority nursing intervention?
A) Administer antihypertensive medication as prescribed
B) Provide patient education on lifestyle modifications and medication
adherence
C) Obtain a baseline electrocardiogram (ECG)
D) Restrict the patient's fluid intake
Answer: B — Provide patient education on lifestyle modifications and
medication adherence
Rationale: The priority nursing intervention for a patient with newly diagnosed
hypertension is patient education on lifestyle modifications (dietary changes,
weight management, exercise, smoking cessation) and medication adherence.
Hypertension is a chronic condition that requires ongoing management. While
medication administration and diagnostic testing are important, education is the
foundation for long-term management and prevention of complications. Patient
education empowers the patient to take an active role in their care.
Q2. A nurse is assessing a patient who is 24 hours post-operative following
abdominal surgery. The patient reports a pain level of 6/10. Which of the following
is the most appropriate nursing action?
A) Administer the prescribed analgesic immediately
B) Assess the patient's pain using a standardized pain scale and administer
the prescribed analgesic
C) Encourage the patient to use non-pharmacological pain management techniques
D) Document the pain level and reassess in 4 hours
,Answer: B — Assess the patient's pain using a standardized pain scale and
administer the prescribed analgesic
Rationale: Pain assessment should be performed using a standardized pain scale
(e.g., numeric rating scale, Wong-Baker FACES scale). The nurse should assess
the pain and administer the prescribed analgesic as ordered. Pain is the fifth
vital sign and should be assessed regularly. Non-pharmacological interventions can
be used as adjuncts, but pharmacological intervention is needed for moderate to
severe pain (6/10). Reassessment is essential to evaluate the effectiveness of the
intervention.
Q3. A nurse is preparing to perform a sterile dressing change for a patient with a
surgical wound. Which of the following is a key principle of sterile technique?
A) The sterile field may be left unattended
B) Sterile items should only be touched by other sterile items
C) The edges of the sterile field are considered sterile
D) Sterile gloves may be touched by unsterile hands
Answer: B — Sterile items should only be touched by other sterile items
Rationale: Key principles of sterile technique include: sterile items should only
be touched by other sterile items, the sterile field must be kept within the nurse's
line of sight and above waist level, the edges of the sterile field are considered
contaminated (1-inch border), and once the sterile field is set up, it should not be
left unattended. Sterile gloves should only be touched by other sterile gloves.
Contamination of the sterile field requires re-establishment of the field.
Q4. A nurse is assessing a patient's pain using the PQRST mnemonic. What does
the "Q" in PQRST stand for?
A) Quantity
B) Quality
C) Quick
D) Question
Answer: B — Quality
,Rationale: The PQRST mnemonic is used for pain
assessment: P (Provocation/Palliation), Q (Quality), R (Radiation/Region), S (Seve
rity), and T (Timing). The "Q" assesses the quality of the pain (e.g., sharp, dull,
burning, aching, throbbing). This helps differentiate types of pain and identify the
underlying cause. Pain is subjective and requires thorough assessment.
Q5. A nurse is monitoring a patient receiving a blood transfusion. The patient
develops fever, chills, and hypotension. Which of the following is the priority
nursing action?
A) Slow the transfusion rate
B) Stop the transfusion immediately and notify the provider
C) Administer antipyretics
D) Continue the transfusion and monitor the patient
Answer: B — Stop the transfusion immediately and notify the provider
Rationale: The patient is exhibiting signs of a transfusion reaction (acute
hemolytic reaction). The priority is to stop the transfusion immediately, notify
the provider, and maintain the IV line with normal saline. The nurse should
assess the patient's vital signs, monitor for signs of shock, and send the blood
product and patient's blood sample to the laboratory. Transfusion reactions are
medical emergencies. Fever, chills, and hypotension are classic signs of an acute
hemolytic reaction.
Q6. A nurse is assessing a patient's risk for falls. Which of the following
interventions is most appropriate for a patient at high risk for falls?
A) Place all four bed rails up
B) Place the bed in the lowest position and use bed alarms
C) Restrain the patient
D) Dim the lights
Answer: B — Place the bed in the lowest position and use bed alarms
Rationale: For patients at high risk for falls, interventions include: placing the
bed in the lowest position, using bed alarms, ensuring the call light is within
reach, providing non-slip socks, and performing frequent rounding. Physical
, restraints should be avoided unless absolutely necessary and only used with a
provider's order. Placing all four bed rails up is considered a restraint and should be
avoided. Adequate lighting is important for visibility, not dim lighting.
Q7. A nurse is administering a medication via the intramuscular (IM) route. Which
of the following is the correct site for an IM injection in an adult?
A) The vastus lateralis
B) The ventrogluteal site
C) The dorsogluteal site
D) The deltoid
Answer: B — The ventrogluteal site
Rationale: The ventrogluteal site is the preferred site for intramuscular injections
in adults due to its location away from major nerves and blood vessels. The
dorsogluteal site is no longer recommended due to the proximity of the sciatic
nerve. The vastus lateralis is the preferred site for infants and toddlers. The deltoid
is used for smaller volumes (up to 2 mL). The ventrogluteal site is located in the
hip area and is identified by the triangle formed by the anterior superior iliac spine,
the iliac crest, and the greater trochanter.
Q8. A nurse is assessing a patient's fluid status. Which of the following findings
indicates fluid overload?
A) Decreased jugular venous distention
B) Crackles in the lung bases and peripheral edema
C) Increased urine output
D) Dry mucous membranes
Answer: B — Crackles in the lung bases and peripheral edema
Rationale: Fluid overload presents with crackles (pulmonary edema), peripheral
edema, jugular venous distention, weight gain, and shortness of breath.
Decreased urine output, not increased, is seen in fluid overload. Dry mucous
membranes suggest dehydration. Fluid overload is common in patients with heart
failure, renal failure, or excessive IV fluid administration.
