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ADULT HEALTH II FINAL REVIEW EXAM |
QUESTIONS & CORRECT ANSWERS WITH
RATIONALES | ALREADY GRADED A BRAND
NEW VERSION! (2025/2026)
1. A nurse on a medical unit is caring for a client who suddenly
becomes confused and drowsy. Additional data includes pulse
100/min, respiratory rate 24/min, BP 132/76 mm Hg, and
temperature 36.8º C (98.2º F). Which of the following actions
should the nurse perform? CORRECT ANSWER - Complete a
neurological check.
Neurological assessment is an appropriate nursing intervention when a client displays
sudden confusion. Sensory alterations can occur when a client is experiencing multiple
sensory stimuli and can result in inappropriate sensory responses. Tolerance to stimuli
may be attected by fatigue and emotional and physical well-being.
2. A nurse at an ophthalmology clinic is providing teaching to a
client who has open angle glaucoma and a new prescription for
timolol eye drops. Which of the following instructions should the
nurse provide? CORRECT ANSWER - The medication should be applied
on a regular schedule for the rest of the client's life.
Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow,
or decrease its production, or both. The client must continue the eye drops on an
uninterrupted basis for life to maintain intraocular pressure at an acceptable level.
3. A nurse is teaching a client who has urolithiasis (renal
calculi). The nurse should explain that which of the following
conditions can increase the risk for renal calculi? CORRECT
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ANSWER - Dehydration
Dehydration can cause hypercalcemia which increases the risk for renal stone formation.
Inadequate fluid intake can result in urinary stasis and promote the formation of calculi.
4. A nurse is modifying the diet of a client who has Parkinson's
disease and is prescribed selegiline, an MAOI. Which of the
following foods should the nurse eliminate? CORRECT ANSWER -
Cheddar cheese
The nurse should eliminate aged cheeses from the diet of a client who is prescribed
selegiline. Cheddar cheese contains tyramine, which can cause a hypertensive crisis.
5. A nurse on an oncology unit is assessing a child who has a
brain tumor. Which of the following findings should the nurse
expect? CORRECT ANSWER - Hyporeflexia
The nurse should expect a child who has a brain tumor to exhibit hyporeflexia and
hyperreflexia.
6. A nurse is caring for a child who is having a tonic-clonic
seizure and vomiting. Which of the following actions is the nurse's
priority? CORRECT ANSWER - Position the child side-lying.
This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should
place the child in a side-lying position.
7. A nurse is discussing kidney transplant with a client who
has end-stage renal disease (ESRD). Which of the following
should the nurse identify as a contraindication for this
treatment? CORRECT ANSWER - Alcohol use disorder
The nurse should identify that a substance use disorder is a contraindication for kidney
transplant.
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8. A nurse is assessing a client who has chronic kidney disease
for fluid volume increase. Which of the following provides a
reliable measure of fluid retention?-
CORRECT ANSWER - Daily weight
Obtaining a client's daily weight and comparing it to previous weights is a reliable method
for measuring a client's fluid volume over time
9. A nurse is caring for a client who is experiencing Cushing's
Triad following a subdural hematoma. Which of the following
medications should the nurse plan to administer? CORRECT
ANSWER - Mannitol 25%
Cushing's Triad is an indication that the client is experiencing increased intracranial
pressure. The nurse should administer mannitol 25%, an osmotic diuretic that promotes
diuresis to treat cerebral edema
10. A nurse is caring for a client immediately following a
hemodialysis treatment. For which of the following
manifestations will the nurse administer a PRN dose of phenytoin?
CORRECT ANSWER - Headache, restlessness
Headache and restlessness are manifestations of disequilibrium syndrome, which occurs
during or after hemodialysis due to the rapid shift of fluids, pH, and osmolarity between
fluid and blood that occurs.. This condition can cause cerebral edema leading to seizures
and coma, and a PRN dose of the anticonvulsant phenytoin should be administered.
11. A nurse is caring for a child who is having a seizure. Which of
the following actions should the nurse take? (Select all that apply.)
CORRECT ANSWER - Assess the client's airway patency
is correct. The nurse should continually assess the client's airway during a seizure.Place
a tongue depressor in the client's mouth is incorrect. Placing something in the client's
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mouth can cause injury.Remove objects from the client's bed is correct. The nurse should
remove objects that can cause injury to the client during a seizure.Place the client
in a side-lying position is correct. The client should be positioned side-lying to prevent
aspiration of secretions or vomit.Restrain the client is incorrect. Restraining the client can
cause injury.
12. A nurse is in a client's room when the client begins having a
tonic-clonic seizure. Which of the following actions should the
nurse take first? CORRECT ANSWER - Turn the client's head to the
side.
The first action the nurse should take when using the airway, breathing, circulation
approach to client care is to turn the client's head to the side. This action keeps the
client's airway clear of secretion to prevent aspiration.
13. A nurse is providing teaching to a client who has nephrotic
syndrome. The nurse should recognize that which of the
following client statements indicates a need for further teaching?
CORRECT ANSWER - "I should increase my sodium intake."
A client who has nephrotic syndrome should consume a low-sodium diet to reduce edem
and control hypertension.
14. A nurse is caring for a client who reports recurrent flank
pain, nausea, and vomiting for 24 hr. Which of the following
actions is the nurse's priority? CORRECT ANSWER - Administer
pain medication.
Using Maslow's hierarchy of needs, the nurse's priority is to meet the client's physiological
need for comfort. Therefore, the first action the nurse should take is to administer pain
medication to relieve the client's flank pain.
ADULT HEALTH II FINAL REVIEW EXAM |
QUESTIONS & CORRECT ANSWERS WITH
RATIONALES | ALREADY GRADED A BRAND
NEW VERSION! (2025/2026)
1. A nurse on a medical unit is caring for a client who suddenly
becomes confused and drowsy. Additional data includes pulse
100/min, respiratory rate 24/min, BP 132/76 mm Hg, and
temperature 36.8º C (98.2º F). Which of the following actions
should the nurse perform? CORRECT ANSWER - Complete a
neurological check.
Neurological assessment is an appropriate nursing intervention when a client displays
sudden confusion. Sensory alterations can occur when a client is experiencing multiple
sensory stimuli and can result in inappropriate sensory responses. Tolerance to stimuli
may be attected by fatigue and emotional and physical well-being.
2. A nurse at an ophthalmology clinic is providing teaching to a
client who has open angle glaucoma and a new prescription for
timolol eye drops. Which of the following instructions should the
nurse provide? CORRECT ANSWER - The medication should be applied
on a regular schedule for the rest of the client's life.
Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow,
or decrease its production, or both. The client must continue the eye drops on an
uninterrupted basis for life to maintain intraocular pressure at an acceptable level.
3. A nurse is teaching a client who has urolithiasis (renal
calculi). The nurse should explain that which of the following
conditions can increase the risk for renal calculi? CORRECT
,2|Page
ANSWER - Dehydration
Dehydration can cause hypercalcemia which increases the risk for renal stone formation.
Inadequate fluid intake can result in urinary stasis and promote the formation of calculi.
4. A nurse is modifying the diet of a client who has Parkinson's
disease and is prescribed selegiline, an MAOI. Which of the
following foods should the nurse eliminate? CORRECT ANSWER -
Cheddar cheese
The nurse should eliminate aged cheeses from the diet of a client who is prescribed
selegiline. Cheddar cheese contains tyramine, which can cause a hypertensive crisis.
5. A nurse on an oncology unit is assessing a child who has a
brain tumor. Which of the following findings should the nurse
expect? CORRECT ANSWER - Hyporeflexia
The nurse should expect a child who has a brain tumor to exhibit hyporeflexia and
hyperreflexia.
6. A nurse is caring for a child who is having a tonic-clonic
seizure and vomiting. Which of the following actions is the nurse's
priority? CORRECT ANSWER - Position the child side-lying.
This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should
place the child in a side-lying position.
7. A nurse is discussing kidney transplant with a client who
has end-stage renal disease (ESRD). Which of the following
should the nurse identify as a contraindication for this
treatment? CORRECT ANSWER - Alcohol use disorder
The nurse should identify that a substance use disorder is a contraindication for kidney
transplant.
,3|Page
8. A nurse is assessing a client who has chronic kidney disease
for fluid volume increase. Which of the following provides a
reliable measure of fluid retention?-
CORRECT ANSWER - Daily weight
Obtaining a client's daily weight and comparing it to previous weights is a reliable method
for measuring a client's fluid volume over time
9. A nurse is caring for a client who is experiencing Cushing's
Triad following a subdural hematoma. Which of the following
medications should the nurse plan to administer? CORRECT
ANSWER - Mannitol 25%
Cushing's Triad is an indication that the client is experiencing increased intracranial
pressure. The nurse should administer mannitol 25%, an osmotic diuretic that promotes
diuresis to treat cerebral edema
10. A nurse is caring for a client immediately following a
hemodialysis treatment. For which of the following
manifestations will the nurse administer a PRN dose of phenytoin?
CORRECT ANSWER - Headache, restlessness
Headache and restlessness are manifestations of disequilibrium syndrome, which occurs
during or after hemodialysis due to the rapid shift of fluids, pH, and osmolarity between
fluid and blood that occurs.. This condition can cause cerebral edema leading to seizures
and coma, and a PRN dose of the anticonvulsant phenytoin should be administered.
11. A nurse is caring for a child who is having a seizure. Which of
the following actions should the nurse take? (Select all that apply.)
CORRECT ANSWER - Assess the client's airway patency
is correct. The nurse should continually assess the client's airway during a seizure.Place
a tongue depressor in the client's mouth is incorrect. Placing something in the client's
,4|Page
mouth can cause injury.Remove objects from the client's bed is correct. The nurse should
remove objects that can cause injury to the client during a seizure.Place the client
in a side-lying position is correct. The client should be positioned side-lying to prevent
aspiration of secretions or vomit.Restrain the client is incorrect. Restraining the client can
cause injury.
12. A nurse is in a client's room when the client begins having a
tonic-clonic seizure. Which of the following actions should the
nurse take first? CORRECT ANSWER - Turn the client's head to the
side.
The first action the nurse should take when using the airway, breathing, circulation
approach to client care is to turn the client's head to the side. This action keeps the
client's airway clear of secretion to prevent aspiration.
13. A nurse is providing teaching to a client who has nephrotic
syndrome. The nurse should recognize that which of the
following client statements indicates a need for further teaching?
CORRECT ANSWER - "I should increase my sodium intake."
A client who has nephrotic syndrome should consume a low-sodium diet to reduce edem
and control hypertension.
14. A nurse is caring for a client who reports recurrent flank
pain, nausea, and vomiting for 24 hr. Which of the following
actions is the nurse's priority? CORRECT ANSWER - Administer
pain medication.
Using Maslow's hierarchy of needs, the nurse's priority is to meet the client's physiological
need for comfort. Therefore, the first action the nurse should take is to administer pain
medication to relieve the client's flank pain.
