Nursing of Adults 1 Final Exam
The nurse plans to complete a thorough assessment of an older patient. Which method should
the nurse use to gather the most complete information?
A) Review the patient's health record for previous assessments
B) Ask the patient to write down medical problems and medications
C) Interview both the patient and the primary caregiver for the patient
D) Use a geriatric assessment instrument to evaluate the patient - ANS D) Use a geriatric
assessment instrument to evaluate the patient
Which intervention should the nurse implement to provide optimal care for an older patient
hospitalized with pneumonia?
A) Use standardized geriatric care plan
B) Minimize physical activity during hospitalization
C) consider the preadmission functional abilities
D) Plan for transfer to a long-term care facility - ANS C) consider the preadmission functional
abilities
The nurse cares for an older adult patient who lives in a rural area. Which intervention should
the nurse plan to implement to best meet this patient's needs?
A) Suggest that the patient move closer to health care providers
B) Ensure transportation to appointments with the health care provider
C) Obtain extra medications for the patient to last for 4 to 6 months
D) Assess the patient for chronic diseases that are unique to rural areas - ANS B) Ensure
transportation to appointments with the health care provider
Which nursing action will be most helpful in decreasing the risk of drug-drug interactions in an
older adult
A) Make a schedule for the patient as a reminder of when to take each medication
B) Teach the patient to have all prescriptions filled at the same pharmacy
C) Instruct the patient to avoid taking over the counter medications or supplements
D) Ask the patient to bring all medications, supplements, and herbs to each appointment - ANS
D) Ask the patient to bring all medications, supplements, and herbs to each appointment
The nurse will assess an older patient who takes diuretics and has a possible urinary tract
infection. Which action should the nurse take first?
A) Request the patient empty the bladder
B) Question the patient about hematuria
C) Palpate over the suprapubic area
D) Inspect for abdominal distension - ANS A) Request the patient empty the bladder
,An older adult being admitted is assessed at high risk for falls. Which action should the nurse
take first?
A) Position the patient in a geriatric recliner with locking tray
B) Ask the health care provider to order a vest restraint
C) Use a bed alarm system on the patient's bed
D) Administer the prescribed PRN sedative medication - ANS C) Use a bed alarm system on
the patient's bed
The nurse manages the care of older adults in an adult health day care center. Whichaction can
the nurse delegate to unlicensed assistive personnel (UAP)?
a. Obtain information about food and medication allergies from patients.
b. Take blood pressures daily and document in individual patient records.
c. Choose social activities based on the individual patient needs and desires.
d. Teach family members how to cope with patients who are cognitively impaired. - ANS b. Take
blood pressures daily and document in individual patient records.
A patient who uses a fentanyl (Duragesic) patch for chronic abdominal pain caused by ovarian
cancer asks the nurse to administer the prescribed hydrocodone tablets, but the patient is
asleep when the nurse returns with the medication. Which action is best for the nurse to take?
a. Wake the patient and administer the hydrocodone.
b. Wait until the patient wakes up and reassess the pain.
c. Suggest the use of nondrug therapies for pain relief instead of additional opioids.
d. Consult with the health care provider about changing the fentanyl (Duragesic) dose. - ANS a.
Wake the patient and administer the hydrocodone.
A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic
arthritic joint pain after a traumatic injury complains of nausea and abdominal fullness. Which
action should the nurse take initially?
a. Administer the ordered antiemetic medication.
b. Order the patient a clear liquid diet until the nausea decreases.
c. Tell the patient that the nausea should subside in about a week.
d. Consult with the health care provider about using a different opioid - ANS a. Administer the
ordered antiemetic medication.
The nurse reviews the medication orders for an older patient with arthritis in both hips who
reports level 3 (0 to 10 scale) hip pain while ambulating. Which medication should the nurse
offer as initial therapy?
a. Naproxen 200 mg orally
b. Oxycodone 5 mg orally
c. Acetaminophen 650 mg orally
d. Aspirin (acetylsalicylic acid) 650 mg orally - ANS c. Acetaminophen 650 mg orally
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness
and warmth around the incision. Which action by the nurse is appropriate?
,a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours. - ANS b. Document the assessment.
A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of
101.8° F (38.7° C) The patient reports having no discomfort. Which action by the nurse is
appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Check the patient's temperature again in 4 hours.
d. Give acetaminophen (Tylenol) prescribed PRN for pain. - ANS c. Check the patient's
temperature again in 4 hours.
The nurse notes that a patient's open abdominal wound widens as it extends deeper into the
abdomen. How would the nurse document this characteristic?
a. Eschar
b. Slough
c. Maceration
d. Undermining - ANS d. Undermining
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which
nursing action is most likely to detect early signs of infection in this patient?
a. Monitor white blood cell counts.
b. Check the skin for areas of redness.
c. Measure the temperature every 2 hours.
d. Ask about feelings of fatigue or malaise. - ANS d. Ask about feelings of fatigue or malaise.
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer.
The base of the wound involves subcutaneous tissue. How should the nurse classify this
pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV - ANS c. Stage III
A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous
tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness
or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure
ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone,
muscle, or supporting tissues.
, A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for
at home by his family. To prevent further tissue damage, what instructions are most important for
the nurse to teach the patient and family?
a. Change the patient's bedding frequently.
b. Apply a hydrocolloid dressing over the ulcer.
c. Change the patient's position every 1 to 2 hours.
d. Record the size and appearance of the ulcer weekly. - ANS c. Change the patient's position
every 1 to 2 hours.
A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which
action by the nurse is appropriate?
a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle.
c. Ask the patient to try bearing weight on the ankle.
d. Assess the ankle's passive range of motion (ROM). - ANS a. Elevate the ankle above heart
level.
When admitting a patient with stage III pressure ulcers on both heels, which information
obtained by the nurse will have the most impact on wound healing?
a. The patient has had the heel ulcers for 6 months.
b. The patient takes oral hypoglycemic agents daily.
c. The patient states that the ulcers are very painful.
d. The patient has several incisions that formed keloids. - ANS b. The patient takes oral
hypoglycemic agents daily.
After receiving a change-of-shift report, which patient should the nurse assess first?
a. The patient who has multiple leg wounds with eschar to be debrided
b. The patient receiving chemotherapy who has a temperature of 102° F
c. The patient who requires analgesics before a scheduled dressing change d. The newly
admitted patient with a stage IV pressure ulcer on the coccyx - ANS b. The patient receiving
chemotherapy who has a temperature of 102° F
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?
a. Blood glucose of 136 mg/dL
b. Oral temperature of 101° F (38.3° C) c. Separation of the proximal wound edges
d. Patient complaint of increased incisional pain - ANS c. Separation of the proximal wound
edges
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?
a. "Benign tumors do not cause damage to other tissues."
b. "Benign tumors are likely to recur in the same location."
c. "Malignant tumors may spread to other tissues or organs."
The nurse plans to complete a thorough assessment of an older patient. Which method should
the nurse use to gather the most complete information?
A) Review the patient's health record for previous assessments
B) Ask the patient to write down medical problems and medications
C) Interview both the patient and the primary caregiver for the patient
D) Use a geriatric assessment instrument to evaluate the patient - ANS D) Use a geriatric
assessment instrument to evaluate the patient
Which intervention should the nurse implement to provide optimal care for an older patient
hospitalized with pneumonia?
A) Use standardized geriatric care plan
B) Minimize physical activity during hospitalization
C) consider the preadmission functional abilities
D) Plan for transfer to a long-term care facility - ANS C) consider the preadmission functional
abilities
The nurse cares for an older adult patient who lives in a rural area. Which intervention should
the nurse plan to implement to best meet this patient's needs?
A) Suggest that the patient move closer to health care providers
B) Ensure transportation to appointments with the health care provider
C) Obtain extra medications for the patient to last for 4 to 6 months
D) Assess the patient for chronic diseases that are unique to rural areas - ANS B) Ensure
transportation to appointments with the health care provider
Which nursing action will be most helpful in decreasing the risk of drug-drug interactions in an
older adult
A) Make a schedule for the patient as a reminder of when to take each medication
B) Teach the patient to have all prescriptions filled at the same pharmacy
C) Instruct the patient to avoid taking over the counter medications or supplements
D) Ask the patient to bring all medications, supplements, and herbs to each appointment - ANS
D) Ask the patient to bring all medications, supplements, and herbs to each appointment
The nurse will assess an older patient who takes diuretics and has a possible urinary tract
infection. Which action should the nurse take first?
A) Request the patient empty the bladder
B) Question the patient about hematuria
C) Palpate over the suprapubic area
D) Inspect for abdominal distension - ANS A) Request the patient empty the bladder
,An older adult being admitted is assessed at high risk for falls. Which action should the nurse
take first?
A) Position the patient in a geriatric recliner with locking tray
B) Ask the health care provider to order a vest restraint
C) Use a bed alarm system on the patient's bed
D) Administer the prescribed PRN sedative medication - ANS C) Use a bed alarm system on
the patient's bed
The nurse manages the care of older adults in an adult health day care center. Whichaction can
the nurse delegate to unlicensed assistive personnel (UAP)?
a. Obtain information about food and medication allergies from patients.
b. Take blood pressures daily and document in individual patient records.
c. Choose social activities based on the individual patient needs and desires.
d. Teach family members how to cope with patients who are cognitively impaired. - ANS b. Take
blood pressures daily and document in individual patient records.
A patient who uses a fentanyl (Duragesic) patch for chronic abdominal pain caused by ovarian
cancer asks the nurse to administer the prescribed hydrocodone tablets, but the patient is
asleep when the nurse returns with the medication. Which action is best for the nurse to take?
a. Wake the patient and administer the hydrocodone.
b. Wait until the patient wakes up and reassess the pain.
c. Suggest the use of nondrug therapies for pain relief instead of additional opioids.
d. Consult with the health care provider about changing the fentanyl (Duragesic) dose. - ANS a.
Wake the patient and administer the hydrocodone.
A patient who has just started taking sustained-release morphine sulfate (MS Contin) for chronic
arthritic joint pain after a traumatic injury complains of nausea and abdominal fullness. Which
action should the nurse take initially?
a. Administer the ordered antiemetic medication.
b. Order the patient a clear liquid diet until the nausea decreases.
c. Tell the patient that the nausea should subside in about a week.
d. Consult with the health care provider about using a different opioid - ANS a. Administer the
ordered antiemetic medication.
The nurse reviews the medication orders for an older patient with arthritis in both hips who
reports level 3 (0 to 10 scale) hip pain while ambulating. Which medication should the nurse
offer as initial therapy?
a. Naproxen 200 mg orally
b. Oxycodone 5 mg orally
c. Acetaminophen 650 mg orally
d. Aspirin (acetylsalicylic acid) 650 mg orally - ANS c. Acetaminophen 650 mg orally
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness
and warmth around the incision. Which action by the nurse is appropriate?
,a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours. - ANS b. Document the assessment.
A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of
101.8° F (38.7° C) The patient reports having no discomfort. Which action by the nurse is
appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Check the patient's temperature again in 4 hours.
d. Give acetaminophen (Tylenol) prescribed PRN for pain. - ANS c. Check the patient's
temperature again in 4 hours.
The nurse notes that a patient's open abdominal wound widens as it extends deeper into the
abdomen. How would the nurse document this characteristic?
a. Eschar
b. Slough
c. Maceration
d. Undermining - ANS d. Undermining
A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which
nursing action is most likely to detect early signs of infection in this patient?
a. Monitor white blood cell counts.
b. Check the skin for areas of redness.
c. Measure the temperature every 2 hours.
d. Ask about feelings of fatigue or malaise. - ANS d. Ask about feelings of fatigue or malaise.
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer.
The base of the wound involves subcutaneous tissue. How should the nurse classify this
pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV - ANS c. Stage III
A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous
tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness
or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure
ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone,
muscle, or supporting tissues.
, A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for
at home by his family. To prevent further tissue damage, what instructions are most important for
the nurse to teach the patient and family?
a. Change the patient's bedding frequently.
b. Apply a hydrocolloid dressing over the ulcer.
c. Change the patient's position every 1 to 2 hours.
d. Record the size and appearance of the ulcer weekly. - ANS c. Change the patient's position
every 1 to 2 hours.
A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which
action by the nurse is appropriate?
a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle.
c. Ask the patient to try bearing weight on the ankle.
d. Assess the ankle's passive range of motion (ROM). - ANS a. Elevate the ankle above heart
level.
When admitting a patient with stage III pressure ulcers on both heels, which information
obtained by the nurse will have the most impact on wound healing?
a. The patient has had the heel ulcers for 6 months.
b. The patient takes oral hypoglycemic agents daily.
c. The patient states that the ulcers are very painful.
d. The patient has several incisions that formed keloids. - ANS b. The patient takes oral
hypoglycemic agents daily.
After receiving a change-of-shift report, which patient should the nurse assess first?
a. The patient who has multiple leg wounds with eschar to be debrided
b. The patient receiving chemotherapy who has a temperature of 102° F
c. The patient who requires analgesics before a scheduled dressing change d. The newly
admitted patient with a stage IV pressure ulcer on the coccyx - ANS b. The patient receiving
chemotherapy who has a temperature of 102° F
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?
a. Blood glucose of 136 mg/dL
b. Oral temperature of 101° F (38.3° C) c. Separation of the proximal wound edges
d. Patient complaint of increased incisional pain - ANS c. Separation of the proximal wound
edges
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?
a. "Benign tumors do not cause damage to other tissues."
b. "Benign tumors are likely to recur in the same location."
c. "Malignant tumors may spread to other tissues or organs."
