ADULT HEALTH UPDATED TEST PAPER
QUESTIONS AND ANSWERS SET A+
✔✔ A central venous catheter has been inserted via a jugular vein, and a radiograph
has confirmed placement of the catheter. A prescription has been received for a
medication STAT, but IV fluids have not yet been started. Which action should the nurse
take prior to administering the prescribed medication?
A. Assess for signs of jugular venous distention.
B. Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D. Flush the line with normal saline. - ✔✔Answer, D
Rationale- Medication can be administered via a central line without additional IV fluids.
The line should first be flushed with a normal saline solution to ensure patency.
Insufficient evidence exists on the effectiveness of flushing catheters with heparin.
Option A will not affect the decision to administer the medication and is not a priority.
Administration of the medication STAT is of greater priority than option B.
✔✔A client is ready for discharge following the creation of an ileostomy. Which
instruction should the nurse include in discharge teaching?
A. Replace the stoma appliance every day.
B. Use warm tap water to irrigate the ileostomy.
C. Change the bag when the seal is broken.
, D. Measure and record the ileostomy output. - ✔✔Answer- C
Rationale- A seal must be maintained to prevent leakage of irritating liquid stool onto the
skin. Option A is excessive and can cause skin irritation and breakdown. Ileostomies
produce liquid fecal drainage, so option B is not necessary. Option D is not needed.
✔✔An older male client comes to the outpatient clinic complaining of pain in his left calf.
The nurse notices a reddened area on the calf of his right leg that is warm to the touch,
and the nurse suspects that the client may have thrombophlebitis. Which additional
assessment is most important for the nurse to perform?
A. Measure the client's calf circumference.
B. Auscultate the client's breath sounds.
C. Observe for ecchymosis and petechiae.
D. Obtain the client's blood pressure. - ✔✔Answer- B
Rationale- All these techniques provide useful assessment data. The most important is
to auscultate the client's breath sounds because the client may have a pulmonary
embolus secondary to the thrombophlebitis. Option A may provide data that support the
nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment because
bruising is not a typical finding associated with thrombophlebitis. Option D is always
useful in evaluating the client's response to a problem but is of less immediate priority
than breath sound auscultation.
✔✔The nurse is caring for a critically ill client with cirrhosis of the liver who has a
nasogastric tube draining bright red blood. The nurse notes that the client's serum
hemoglobin and hematocrit levels are decreased. Which additional change in laboratory
data should the nurse expect?
A. Increased serum albumin level
B. Decreased serum creatinine
C. Decreased serum ammonia level
D. Increased liver function test results - ✔✔Answer- C
QUESTIONS AND ANSWERS SET A+
✔✔ A central venous catheter has been inserted via a jugular vein, and a radiograph
has confirmed placement of the catheter. A prescription has been received for a
medication STAT, but IV fluids have not yet been started. Which action should the nurse
take prior to administering the prescribed medication?
A. Assess for signs of jugular venous distention.
B. Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D. Flush the line with normal saline. - ✔✔Answer, D
Rationale- Medication can be administered via a central line without additional IV fluids.
The line should first be flushed with a normal saline solution to ensure patency.
Insufficient evidence exists on the effectiveness of flushing catheters with heparin.
Option A will not affect the decision to administer the medication and is not a priority.
Administration of the medication STAT is of greater priority than option B.
✔✔A client is ready for discharge following the creation of an ileostomy. Which
instruction should the nurse include in discharge teaching?
A. Replace the stoma appliance every day.
B. Use warm tap water to irrigate the ileostomy.
C. Change the bag when the seal is broken.
, D. Measure and record the ileostomy output. - ✔✔Answer- C
Rationale- A seal must be maintained to prevent leakage of irritating liquid stool onto the
skin. Option A is excessive and can cause skin irritation and breakdown. Ileostomies
produce liquid fecal drainage, so option B is not necessary. Option D is not needed.
✔✔An older male client comes to the outpatient clinic complaining of pain in his left calf.
The nurse notices a reddened area on the calf of his right leg that is warm to the touch,
and the nurse suspects that the client may have thrombophlebitis. Which additional
assessment is most important for the nurse to perform?
A. Measure the client's calf circumference.
B. Auscultate the client's breath sounds.
C. Observe for ecchymosis and petechiae.
D. Obtain the client's blood pressure. - ✔✔Answer- B
Rationale- All these techniques provide useful assessment data. The most important is
to auscultate the client's breath sounds because the client may have a pulmonary
embolus secondary to the thrombophlebitis. Option A may provide data that support the
nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment because
bruising is not a typical finding associated with thrombophlebitis. Option D is always
useful in evaluating the client's response to a problem but is of less immediate priority
than breath sound auscultation.
✔✔The nurse is caring for a critically ill client with cirrhosis of the liver who has a
nasogastric tube draining bright red blood. The nurse notes that the client's serum
hemoglobin and hematocrit levels are decreased. Which additional change in laboratory
data should the nurse expect?
A. Increased serum albumin level
B. Decreased serum creatinine
C. Decreased serum ammonia level
D. Increased liver function test results - ✔✔Answer- C
