HURST ADULT HEALTH EXAM REVIEW UPDATED FOR 2025 ACTUAL QUESTIONS
WITH 100% VERIFIED SOLUTIONS 2023-2025
The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled
but has good capillary refill. What is the nurse's best action at this time?
1. Warm the room.
2. Submerge the hand in warm water.
3. Order a K pad and apply to hand.
4. Have the client exercise the fingers to increase blood flow.
1. Correct: When caring for clients with skin grafts, we want good circulation, so warm that
room up.
2. Incorrect: This will not improve circulation and can lead to infection.
3. Incorrect: This will not improve circulation. Someone who has a skin graft doesn't have good
sensation so there is risk of another burn to the graft with this.
4. Incorrect: Working those stiff, cold fingers will further imbalance the oxygen supply. This will
not help, particularly if the environment remains cool.
A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial
assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy
skin, and confusion. Which interventions should the nurse perform?
Select all that apply
1. Initiate cardiac monitoring.
2. Monitor intake and output hourly.
3. Position client in recumbent position.
4. Limit physical activity.
5. Administer dopamine at 5 micrograms/kg/min.
1., 2., 4. & 5. Correct: This client exhibits signs of cardiogenic shock, a complication of
myocardial infarction. Hypotension accompanied by clinical signs of increased peripheral
resistance (weak, thready pulse and cool, clammy skin) and inadequate organ perfusion (altered
mental status and decreased urinary output) are found in this client. Initiate cardiac monitoring,
watching for dysrhythmias, monitor I&O hourly to make sure kidneys are perfused. Limit activity
to decrease oxygen demand. Dopamine is administered to increase BP and cardiac output.
3. Incorrect: Position upright to promote optimal ventilation by reducing venous return and
lessen pulmonary edema.
,The nurse is supervising the care of a client on bedrest with a skull fracture from head trauma.
Which action, when performed by an unlicensed assistive personnel (UAP), should the nurse
interrupt?
1. Assisting with turn, cough, and deep breathing (TCDB)
2. Elevating the head of the bed to 30 degrees.
3. Measuring urinary output every hour.
4. Turning off room lights.
1. Correct: The nurse should interrupt the UAP assisting with TCDB because this may increase
intracranial pressure (ICP). TCDB increases intrathoracic pressure which then increases ICP.
2. Incorrect: Maintain client with head trauma in the head up position. This position promotes
drainage from the head and decreases vascular congestion.
3. Incorrect: This is an acceptable action and one the UAP can do.
4. Incorrect: You want to decrease stimulation and turning off room lights will provide restful
environment in an effort to decrease ICP.
The nurse is caring for a burn client in the emergent phase. The client becomes extremely
restless while on a ventilator. What is the priority nursing assessment?
1. Patency of endotracheal tube.
2. Adventitious breath sounds.
3. Fluid in the ventilator tubing.
4. Ventilator settings.
1. Correct: With restlessness, think hypoxia so the nurse should start assessment with airway
first. Check for patency of the ET tube. If this is patent, then the other options would be next.
2. Incorrect: This is the next best answer, but hypoxia and airway comes first.
3. Incorrect: This is the third step. Rule out the other two before checking tubing for kinks or
obstructions.
4. Incorrect: Start with the client first. Then move toward the ventilator. Always assess the client
first.
,After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse
should implement which intervention?
1. Have the client take slow deep breaths in through the mouth and out through the nose.
2. Post signs on the client's door and in the client's room indicating that oxygen is in use .
3. Apply Vaseline petroleum to both nares and 2 x 2 gauze around the oxygen tubing at the
client's ears.
4. Encourage the client to hyperextend the neck, take a few deep breaths and cough.
2. Correct: This is an oxygen therapy safety precaution that the nurse should implement after
applying oxygen. It is also the only correct and safe option in the question.
1. Incorrect: The bi-nasal prongs would mean that the oxygen is going in through the nose.
Breathing deeply through the mouth and out through the nose would not increase oxygenation
for a client having chest pain and would disrupt the flow of oxygen through the nose.
3. Incorrect: The nurse should avoid using petroleum products where oxygen is in use because
they are flammable.
4. Incorrect: These client actions have nothing to do with oxygen administration and would
cause more distress to the client with chest pain.
A client with a history of myasthenia gravis (MG) has been discharged from the hospital
following a thymectomy. When teaching the client how to prevent complications, the home care
nurse emphasizes what daily actions are most important?
Select all that apply
1. Include daily weight lifting exercises.
2. Practice stress reduction techniques.
3. Complete chores early in the day.
4. Take medications on time and prior to meals.
5. Eat three large meals daily.
2., 3. & 4. Correct: Myasthenia gravis is a chronic autoimmune disorder characterized by
progressive muscle weakening and chronic fatigue. Clients become weaker throughout the day,
contributing to the potential for complications. Stress reduction techniques are important since
stress can contribute to a myasthenic crisis, a severe respiratory emergency. Daily tasks,
including ADL's, should be completed early in the day when the client has the most energy.
Medications for MG, including neostigmine and pyridostigmine, must be taken on time and
prior to meals.
, 1. Incorrect: Clients with myasthenia gravis are instructed to include gentle daily exercise
combined with periods of rest throughout the day. Weight lifting would be too strenuous and
would quickly tire this client, possibly leading to a myasthenia crisis.
5. Incorrect: Because of the difficulty in chewing or swallowing, multiple small meals throughout
the day are safer and more beneficial to a client with myasthenia gravis. Medications are timed
in relation to meals, so consistent but smaller meals would be more beneficial for the client.
A nurse is participating in a cancer risk screening program. Which signs/symptoms would
indicate to the nurse that a client needs further investigation?
Select all that apply
1. Unexplained weight gain of 10 pounds
2. Leukoplakia
3. Prolonged hoarseness
4. Hematuria
5. Persistent abdominal bloating
2., 3., 4., & 5. Correct: White patches inside the mouth or white spots on the tongue may be
leukoplakia, which is a precancerous area that is caused by frequent irritation. It is often caused
by smoking or other tobacco use. People who smoke pipes or use oral or spit tobacco are at
high risk for leukoplakia. If untreated, it can become mouth cancer. A cough that does not go
away and prolonged hoarseness may be a sign of cancer. Hematuria may be a sign of bladder or
kidney cancer and needs further investigation. Although women may experience bloating with
changes in the menstrual cycle, constant bloating should be investigated to rule out ovarian
cancer.
1. Incorrect: Unexplained loss of weight or loss of appetite may indicate some types of cancer.
Weight gain is not typically associated with cancer.
WITH 100% VERIFIED SOLUTIONS 2023-2025
The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled
but has good capillary refill. What is the nurse's best action at this time?
1. Warm the room.
2. Submerge the hand in warm water.
3. Order a K pad and apply to hand.
4. Have the client exercise the fingers to increase blood flow.
1. Correct: When caring for clients with skin grafts, we want good circulation, so warm that
room up.
2. Incorrect: This will not improve circulation and can lead to infection.
3. Incorrect: This will not improve circulation. Someone who has a skin graft doesn't have good
sensation so there is risk of another burn to the graft with this.
4. Incorrect: Working those stiff, cold fingers will further imbalance the oxygen supply. This will
not help, particularly if the environment remains cool.
A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial
assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy
skin, and confusion. Which interventions should the nurse perform?
Select all that apply
1. Initiate cardiac monitoring.
2. Monitor intake and output hourly.
3. Position client in recumbent position.
4. Limit physical activity.
5. Administer dopamine at 5 micrograms/kg/min.
1., 2., 4. & 5. Correct: This client exhibits signs of cardiogenic shock, a complication of
myocardial infarction. Hypotension accompanied by clinical signs of increased peripheral
resistance (weak, thready pulse and cool, clammy skin) and inadequate organ perfusion (altered
mental status and decreased urinary output) are found in this client. Initiate cardiac monitoring,
watching for dysrhythmias, monitor I&O hourly to make sure kidneys are perfused. Limit activity
to decrease oxygen demand. Dopamine is administered to increase BP and cardiac output.
3. Incorrect: Position upright to promote optimal ventilation by reducing venous return and
lessen pulmonary edema.
,The nurse is supervising the care of a client on bedrest with a skull fracture from head trauma.
Which action, when performed by an unlicensed assistive personnel (UAP), should the nurse
interrupt?
1. Assisting with turn, cough, and deep breathing (TCDB)
2. Elevating the head of the bed to 30 degrees.
3. Measuring urinary output every hour.
4. Turning off room lights.
1. Correct: The nurse should interrupt the UAP assisting with TCDB because this may increase
intracranial pressure (ICP). TCDB increases intrathoracic pressure which then increases ICP.
2. Incorrect: Maintain client with head trauma in the head up position. This position promotes
drainage from the head and decreases vascular congestion.
3. Incorrect: This is an acceptable action and one the UAP can do.
4. Incorrect: You want to decrease stimulation and turning off room lights will provide restful
environment in an effort to decrease ICP.
The nurse is caring for a burn client in the emergent phase. The client becomes extremely
restless while on a ventilator. What is the priority nursing assessment?
1. Patency of endotracheal tube.
2. Adventitious breath sounds.
3. Fluid in the ventilator tubing.
4. Ventilator settings.
1. Correct: With restlessness, think hypoxia so the nurse should start assessment with airway
first. Check for patency of the ET tube. If this is patent, then the other options would be next.
2. Incorrect: This is the next best answer, but hypoxia and airway comes first.
3. Incorrect: This is the third step. Rule out the other two before checking tubing for kinks or
obstructions.
4. Incorrect: Start with the client first. Then move toward the ventilator. Always assess the client
first.
,After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse
should implement which intervention?
1. Have the client take slow deep breaths in through the mouth and out through the nose.
2. Post signs on the client's door and in the client's room indicating that oxygen is in use .
3. Apply Vaseline petroleum to both nares and 2 x 2 gauze around the oxygen tubing at the
client's ears.
4. Encourage the client to hyperextend the neck, take a few deep breaths and cough.
2. Correct: This is an oxygen therapy safety precaution that the nurse should implement after
applying oxygen. It is also the only correct and safe option in the question.
1. Incorrect: The bi-nasal prongs would mean that the oxygen is going in through the nose.
Breathing deeply through the mouth and out through the nose would not increase oxygenation
for a client having chest pain and would disrupt the flow of oxygen through the nose.
3. Incorrect: The nurse should avoid using petroleum products where oxygen is in use because
they are flammable.
4. Incorrect: These client actions have nothing to do with oxygen administration and would
cause more distress to the client with chest pain.
A client with a history of myasthenia gravis (MG) has been discharged from the hospital
following a thymectomy. When teaching the client how to prevent complications, the home care
nurse emphasizes what daily actions are most important?
Select all that apply
1. Include daily weight lifting exercises.
2. Practice stress reduction techniques.
3. Complete chores early in the day.
4. Take medications on time and prior to meals.
5. Eat three large meals daily.
2., 3. & 4. Correct: Myasthenia gravis is a chronic autoimmune disorder characterized by
progressive muscle weakening and chronic fatigue. Clients become weaker throughout the day,
contributing to the potential for complications. Stress reduction techniques are important since
stress can contribute to a myasthenic crisis, a severe respiratory emergency. Daily tasks,
including ADL's, should be completed early in the day when the client has the most energy.
Medications for MG, including neostigmine and pyridostigmine, must be taken on time and
prior to meals.
, 1. Incorrect: Clients with myasthenia gravis are instructed to include gentle daily exercise
combined with periods of rest throughout the day. Weight lifting would be too strenuous and
would quickly tire this client, possibly leading to a myasthenia crisis.
5. Incorrect: Because of the difficulty in chewing or swallowing, multiple small meals throughout
the day are safer and more beneficial to a client with myasthenia gravis. Medications are timed
in relation to meals, so consistent but smaller meals would be more beneficial for the client.
A nurse is participating in a cancer risk screening program. Which signs/symptoms would
indicate to the nurse that a client needs further investigation?
Select all that apply
1. Unexplained weight gain of 10 pounds
2. Leukoplakia
3. Prolonged hoarseness
4. Hematuria
5. Persistent abdominal bloating
2., 3., 4., & 5. Correct: White patches inside the mouth or white spots on the tongue may be
leukoplakia, which is a precancerous area that is caused by frequent irritation. It is often caused
by smoking or other tobacco use. People who smoke pipes or use oral or spit tobacco are at
high risk for leukoplakia. If untreated, it can become mouth cancer. A cough that does not go
away and prolonged hoarseness may be a sign of cancer. Hematuria may be a sign of bladder or
kidney cancer and needs further investigation. Although women may experience bloating with
changes in the menstrual cycle, constant bloating should be investigated to rule out ovarian
cancer.
1. Incorrect: Unexplained loss of weight or loss of appetite may indicate some types of cancer.
Weight gain is not typically associated with cancer.
