ADULT HEALTH EXAMINATION QUESTIONS AND
ANSWERS SET A+
✔✔The nurse is caring for a client in the post anesthesia care unit (PACU) who
underwent a thoracotomy two hours ago. The nurse observes the following vital signs:
Heart rate 140 beats/min, respirations 26 breaths/minutes, and blood pressure 140/90
mmHg. Which intervention is most important for the nurse to implement?
a. Medicate for pain and monitor vital signs according to protocol
b. Administer IV fluid bolus as prescribed by the provider
c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter
d. Encourage the client to splint the incision with a pillow to cough and deep breathe -
✔✔a. Medicate for pain and monitor vital signs according to protocol
✔✔An adult client is diagnosed with restless leg syndrome and is referred to the sleep
clinic. The healthcare provider prescribes ferrous sulfate 325 mg Po daily. Which
laboratory values should the nurse monitor?
a. Platelet count and hematocrit
b. serum electrolytes
c. Serum iron and ferritin
d. Neutrophils and eosinophils - ✔✔c. Serum iron and ferritin
✔✔while caring for a client with a full thickness burn covering 40% of the body, the
nurse observes purulent drainage at the wound. Before reporting this finding to the
healthcare provider, the nurse should review which of the following laboratory values?
a. White blood cell count
b. platelet count
c. Blood pH level
d. hematocrit - ✔✔a. White blood cell count
✔✔The nurse is developing a plan of care for a client who reports blurred vision and
who is newly diagnosed with cardiovascular disease. Which outcome should the nurse
include in the plan of care for this client?
a. The nurse will encourage the client to walk thirty minutes every day
, b. The client's family will state signs and symptoms about the disease
c. The clients daily blood pressure will be less than 140/80 mmHg this month
d. The clients blood pressure readings will be less than 150/90 mmHg this month -
✔✔c. The clients daily blood pressure will be less than 140/80 mmHg this month
✔✔The family suspects the acquired immune deficiency syndrome (AIDS) dementia is
occurring in their son who is human immunodeficiency virus (HIV) positive. Which
symptom confirms their suspicions?
a. He has begun to sleep 18 out of 24 hours
b. A change has recently occurred in his handwriting
c. He refuses to see any of his friends or return their phone calls
d. he exhibits angry outbursts when the subject of dying is approached - ✔✔b. A
change has recently occurred in his handwriting
✔✔A hospitalized client with peripheral arterial disease (PAD) is instructed regarding
leg and foot care. Which statement by the client indicates to the nurse that learning has
occurred?
a. "whenever I am sitting in a chair I will keep my legs up to reduce swelling"
b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
c. "I will try to keep moving if leg pain occurs to help promote good circulation"
d. "I will use my swimming pool early in the day while the water is still very cool" - ✔✔b.
"I can use a mirror to check the bottoms of my feet for any signs of breakdown"
✔✔While completing a health assessment for a client with migraine headaches, the
nurse assesses bilateral weakness in the client's hand grips. The client reports joint pain
and trouble twisting a door knob due to weakness. Which action should the nurse take
in response to these findings?
a. Explain that relief of the migraine pain will reduce related symptoms
b. Gather additional assessment data about pain and weakness
c. Implement fall precautions to reduce the client's risk for injury
d. Consult with the occupational therapist for a functional assessment - ✔✔d. Consult
with the occupational therapist for a functional assessment
✔✔The nurse is preparing a client for surgery who was admitted to the emergency
center following a motor vehicle collision. The client has an open fracture of the femur
and is bleeding moderately from the bone protrusion site. During the preoperative
assessment the nurse determines that the client currently receives heparin sodium
5,000 units subcutaneously daily. What is the priority nursing action?
a. Notify the healthcare provider of the client's medication history
b. Observe the heparin injection sites for signs of bruising
c. Have the client sign the surgical and transfusion permits
d. Ensure that the potential for bleeding is explained to the client - ✔✔a. Notify the
healthcare provider of the client's medication history
ANSWERS SET A+
✔✔The nurse is caring for a client in the post anesthesia care unit (PACU) who
underwent a thoracotomy two hours ago. The nurse observes the following vital signs:
Heart rate 140 beats/min, respirations 26 breaths/minutes, and blood pressure 140/90
mmHg. Which intervention is most important for the nurse to implement?
a. Medicate for pain and monitor vital signs according to protocol
b. Administer IV fluid bolus as prescribed by the provider
c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter
d. Encourage the client to splint the incision with a pillow to cough and deep breathe -
✔✔a. Medicate for pain and monitor vital signs according to protocol
✔✔An adult client is diagnosed with restless leg syndrome and is referred to the sleep
clinic. The healthcare provider prescribes ferrous sulfate 325 mg Po daily. Which
laboratory values should the nurse monitor?
a. Platelet count and hematocrit
b. serum electrolytes
c. Serum iron and ferritin
d. Neutrophils and eosinophils - ✔✔c. Serum iron and ferritin
✔✔while caring for a client with a full thickness burn covering 40% of the body, the
nurse observes purulent drainage at the wound. Before reporting this finding to the
healthcare provider, the nurse should review which of the following laboratory values?
a. White blood cell count
b. platelet count
c. Blood pH level
d. hematocrit - ✔✔a. White blood cell count
✔✔The nurse is developing a plan of care for a client who reports blurred vision and
who is newly diagnosed with cardiovascular disease. Which outcome should the nurse
include in the plan of care for this client?
a. The nurse will encourage the client to walk thirty minutes every day
, b. The client's family will state signs and symptoms about the disease
c. The clients daily blood pressure will be less than 140/80 mmHg this month
d. The clients blood pressure readings will be less than 150/90 mmHg this month -
✔✔c. The clients daily blood pressure will be less than 140/80 mmHg this month
✔✔The family suspects the acquired immune deficiency syndrome (AIDS) dementia is
occurring in their son who is human immunodeficiency virus (HIV) positive. Which
symptom confirms their suspicions?
a. He has begun to sleep 18 out of 24 hours
b. A change has recently occurred in his handwriting
c. He refuses to see any of his friends or return their phone calls
d. he exhibits angry outbursts when the subject of dying is approached - ✔✔b. A
change has recently occurred in his handwriting
✔✔A hospitalized client with peripheral arterial disease (PAD) is instructed regarding
leg and foot care. Which statement by the client indicates to the nurse that learning has
occurred?
a. "whenever I am sitting in a chair I will keep my legs up to reduce swelling"
b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
c. "I will try to keep moving if leg pain occurs to help promote good circulation"
d. "I will use my swimming pool early in the day while the water is still very cool" - ✔✔b.
"I can use a mirror to check the bottoms of my feet for any signs of breakdown"
✔✔While completing a health assessment for a client with migraine headaches, the
nurse assesses bilateral weakness in the client's hand grips. The client reports joint pain
and trouble twisting a door knob due to weakness. Which action should the nurse take
in response to these findings?
a. Explain that relief of the migraine pain will reduce related symptoms
b. Gather additional assessment data about pain and weakness
c. Implement fall precautions to reduce the client's risk for injury
d. Consult with the occupational therapist for a functional assessment - ✔✔d. Consult
with the occupational therapist for a functional assessment
✔✔The nurse is preparing a client for surgery who was admitted to the emergency
center following a motor vehicle collision. The client has an open fracture of the femur
and is bleeding moderately from the bone protrusion site. During the preoperative
assessment the nurse determines that the client currently receives heparin sodium
5,000 units subcutaneously daily. What is the priority nursing action?
a. Notify the healthcare provider of the client's medication history
b. Observe the heparin injection sites for signs of bruising
c. Have the client sign the surgical and transfusion permits
d. Ensure that the potential for bleeding is explained to the client - ✔✔a. Notify the
healthcare provider of the client's medication history
