ADULT HEALTH ACTUAL FINALS QUESTIONS AND
ANSWERS SET A+
✔✔The nurse is assessing a male client with acute pancreatitis. Which finding requires
the most immediate intervention by the nurse?
A. The client's amylase level is three times higher than the normal level.
B. While the nurse is taking the client's blood pressure, he has a carpal spasm.
C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7.
D. The client states that he will continue to drink alcohol after going home. -
✔✔Answer- B
Rationale- A positive Trousseau sign indicates hypocalcemia and always requires
further assessment and intervention, regardless of the cause (40% to 75% of those with
acute pancreatitis experience hypocalcemia, which can have serious, systemic effects).
A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two
to five times higher than the normal value. Severe boring pain is an expected symptom
for this diagnosis, but dealing with the hypocalcemia is a priority over administering an
analgesic. Long-term planning and teaching do not have the same immediate
importance as a positive Trousseau sign.
✔✔A male client has just undergone a laryngectomy and has a cuffed tracheostomy
tube in place. When initiating bolus tube feedings postoperatively, when should the
nurse inflate the cuff?
A. Immediately after feeding
,B. Just prior to tube feeding
C. Continuous inflation is required
D. Inflation is not required - ✔✔Answer- B
Rationale- The cuff should be inflated before the feeding to block the trachea and
prevent food from entering if oral feedings are started while a cuffed tracheostomy tube
is in place. It should remain inflated throughout the feeding to prevent aspiration of food
into the respiratory system. Options A and D place the client at risk for aspiration.
Option C places the client at risk for tracheal wall necrosis.
✔✔The nurse initiates neurologic checks for a client who is at risk for neurologic
compromise. Which manifestation typically provides the first indication of altered
neurologic function?
A. Change in level of consciousness
B. Increasing muscular weakness
C. Changes in pupil size bilaterally
D. Progressive nuchal rigidity - ✔✔Answer- A
Rationale- A decrease or change in the level of consciousness is usually the first
indication of neurologic deterioration. Options B and C may also occur but are much
less likely to be the first sign of neurologic compromise. Option D is often a sign of
meningitis.
✔✔Based on the clinical manifestations of Cushing syndrome, which nursing
intervention would be appropriate for a client who is newly diagnosed with Cushing
syndrome?
A. Monitor blood glucose levels daily.
B. Increase intake of fluids high in potassium.
C. Encourage adequate rest between activities.
, D. Offer the client a sodium-enriched menu. - ✔✔Answer- A
Rationale- ushing syndrome results from a hypersecretion of glucocorticoids in the
adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus.
Monitoring of serum glucose levels assesses for increased blood glucose levels so that
treatment can begin early. A common finding in Cushing syndrome is generalized
edema. Although potassium is needed, it is generally obtained from food intake, not by
offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in
Cushing syndrome, so an emphasis on the need for rest is not indicated A low-calorie,
low-carbohydrate, low-sodium diet is not recommended.
✔✔What can insulin do? - ✔✔Increase serum potassium level (and blood glucose of
course)
✔✔The nurse is observing an unlicensed assistive personnel (UAP) performing morning
care for a bedridden client with Huntington disease. Which care measure is most
important for the nurse to supervise?
A. Oral Care
B. Bathing
C. Foot Care
D. catheter care - ✔✔Answer- A
Rationale- The client with Huntington disease experiences problems with motor skills
such as swallowing and is at high risk for aspiration, so the highest priority for the nurse
to observe is the UAP's ability to perform oral care safely. Options B, C, and D do not
necessarily require registered nurse (RN) supervision because they do not ordinarily
pose life-threatening consequences.
✔✔The nurse assesses a postoperative client whose skin is cool, pale, and moist. The
client is very restless and has scant urine output. Oxygen is being administered at 2
L/min, and a saline lock is in place. Which intervention should the nurse implement first?
A. Measure the urine specific gravity.
B. Obtain IV fluids for infusion per protocol.
C. Prepare for insertion of a central venous catheter.
D. Auscultate the client's breath sounds. - ✔✔Answer- B
ANSWERS SET A+
✔✔The nurse is assessing a male client with acute pancreatitis. Which finding requires
the most immediate intervention by the nurse?
A. The client's amylase level is three times higher than the normal level.
B. While the nurse is taking the client's blood pressure, he has a carpal spasm.
C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7.
D. The client states that he will continue to drink alcohol after going home. -
✔✔Answer- B
Rationale- A positive Trousseau sign indicates hypocalcemia and always requires
further assessment and intervention, regardless of the cause (40% to 75% of those with
acute pancreatitis experience hypocalcemia, which can have serious, systemic effects).
A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two
to five times higher than the normal value. Severe boring pain is an expected symptom
for this diagnosis, but dealing with the hypocalcemia is a priority over administering an
analgesic. Long-term planning and teaching do not have the same immediate
importance as a positive Trousseau sign.
✔✔A male client has just undergone a laryngectomy and has a cuffed tracheostomy
tube in place. When initiating bolus tube feedings postoperatively, when should the
nurse inflate the cuff?
A. Immediately after feeding
,B. Just prior to tube feeding
C. Continuous inflation is required
D. Inflation is not required - ✔✔Answer- B
Rationale- The cuff should be inflated before the feeding to block the trachea and
prevent food from entering if oral feedings are started while a cuffed tracheostomy tube
is in place. It should remain inflated throughout the feeding to prevent aspiration of food
into the respiratory system. Options A and D place the client at risk for aspiration.
Option C places the client at risk for tracheal wall necrosis.
✔✔The nurse initiates neurologic checks for a client who is at risk for neurologic
compromise. Which manifestation typically provides the first indication of altered
neurologic function?
A. Change in level of consciousness
B. Increasing muscular weakness
C. Changes in pupil size bilaterally
D. Progressive nuchal rigidity - ✔✔Answer- A
Rationale- A decrease or change in the level of consciousness is usually the first
indication of neurologic deterioration. Options B and C may also occur but are much
less likely to be the first sign of neurologic compromise. Option D is often a sign of
meningitis.
✔✔Based on the clinical manifestations of Cushing syndrome, which nursing
intervention would be appropriate for a client who is newly diagnosed with Cushing
syndrome?
A. Monitor blood glucose levels daily.
B. Increase intake of fluids high in potassium.
C. Encourage adequate rest between activities.
, D. Offer the client a sodium-enriched menu. - ✔✔Answer- A
Rationale- ushing syndrome results from a hypersecretion of glucocorticoids in the
adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus.
Monitoring of serum glucose levels assesses for increased blood glucose levels so that
treatment can begin early. A common finding in Cushing syndrome is generalized
edema. Although potassium is needed, it is generally obtained from food intake, not by
offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in
Cushing syndrome, so an emphasis on the need for rest is not indicated A low-calorie,
low-carbohydrate, low-sodium diet is not recommended.
✔✔What can insulin do? - ✔✔Increase serum potassium level (and blood glucose of
course)
✔✔The nurse is observing an unlicensed assistive personnel (UAP) performing morning
care for a bedridden client with Huntington disease. Which care measure is most
important for the nurse to supervise?
A. Oral Care
B. Bathing
C. Foot Care
D. catheter care - ✔✔Answer- A
Rationale- The client with Huntington disease experiences problems with motor skills
such as swallowing and is at high risk for aspiration, so the highest priority for the nurse
to observe is the UAP's ability to perform oral care safely. Options B, C, and D do not
necessarily require registered nurse (RN) supervision because they do not ordinarily
pose life-threatening consequences.
✔✔The nurse assesses a postoperative client whose skin is cool, pale, and moist. The
client is very restless and has scant urine output. Oxygen is being administered at 2
L/min, and a saline lock is in place. Which intervention should the nurse implement first?
A. Measure the urine specific gravity.
B. Obtain IV fluids for infusion per protocol.
C. Prepare for insertion of a central venous catheter.
D. Auscultate the client's breath sounds. - ✔✔Answer- B
