Adult Health 2019 Proctored

Adult Health 2019 Proctored Exam

• A nurse is preparing to administer thrombolytic therapy to a client who had an ischemic

stroke. Which of the following is an appropriate nursing action?

• Start the therapy within 8 hr
• Insert an indwelling urinary catheter after therapy begins
• Monitor blood pressure every 30 min during the infusion
• Elevate the head of bed between 25 and 30

• A nurse is teaching a client about the use of an incentive spirometer. Which of the following

instructions should the nurse include in the teaching?

• Place hands on the upper abdomen during inhalation
• Exhale slowly through pursed lips
• Hold breaths about 3 to 5 seconds before exhaling
• Position the mouthpiece 2.5 cm (1 in) from the mouth

• A nurse is assessing a client who is 12 hr postoperative following a colon resection. Which of

the following findings should the nurse report to the surgeon?

• Heart rate 90/min
• Hgb 8.2 g/dL
• Gastric pH of 3.0
• Absent bowel sounds

• A nurse is caring for a client who has diabetes insipidus. Which of the following medications

should the nurse plan to administer?

• Regular insulin
• Furosemide
• Desmopressin
• Lithium carbonate

• A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times

daily for 3 years. Which of the following tests should the nurse monitor?

• Stool for occult blood
• Urine for white blood cells
• Fasting blood glucose
• Serum calcium

• A nurse in the emergency department is assessing a client. Which of the following actions

should the nurse take first? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)

• Obtain a sputum sample for culture
• Prepare the client for a chest x-ray
• Initiate airborne precautions
• Administer ondansetron

• A nurse is contacting the provider of a client who has cancer and is experiencing

breakthrough pain. Which of the following prescriptions should the nurse anticipate?

• Intravenous dexamethasone
• Transmucosal fentanyl
• Oral acetaminophen
• Intramuscular meperidine

• A nurse is admitting a client who reports chest pain and has been placed on a telemetry

monitor. Which of the following should the nurse analyze to determine whether the client is experiencing a myocardial infarction?

• QRS duration
• ST segment
• T wave
• PR interval

• A nurse is teaching a client who has ovarian cancer about skin care following radiation

treatment. Which of the following instructions should the nurse include?

• Apply over-the-counter moisturizer to the radiation site
• Cover the radiation site loosely with a gauze wrap before dressing
• Use a soft washcloth to clean the area around the radiation site
• Pat the skin on the radiation site to dry it

• A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that

the client has bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the following prescribed medications?

• Acetaminophen
• Furosemide
• Diphenhydramine
• Pantoprazole

• A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of

hypomagnesemia. Which of the following findings indicates effectiveness of the medication?

• Lungs clear
• Hyperactive bowel sounds
• Blood pressure 90/50 mm Hg
• Apical pulse 82/min

• A nurse is preparing a client for a lumbar puncture. Which of the following images indicates

the position the nurse should assist the client into for this procedure?

Answer is exhibit “C” – picture shows pt lying in side-lying left position

• A nurse is reviewing a client’s ABG results: pH 7.42, PaCO2 30 mm Hg, and HCO3- 21 mEq/L.

The nurse should recognize these findings as an indication of which of the following conditions?

• Compensated respiratory alkalosis
• Uncompensated respiratory acidosis
• Metabolic acidosis
• Metabolic alkalosis

• A nurse is preparing to administer daily medications to a client who is undergoing a

procedure at 1000 that requires IV contrast dye. Which of the following routine medications to give at 0800 should the nurse withhold?

• Metoprolol
• Metformin
• Fluticasone
• Valproic acid

• A nurse is planning care for a client who is experiencing seizures secondary to meningitis.

Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

• Assist the client to ambulate every 4 hr
• Place a tongue blade at the bedside
• Have suction equipment at the bedside
• Dim the overhead lights
• Apply a warming blanket

• A nurse is caring for a client who has a pressure ulcer with necrotic tissue and requires wet-

to-damp dressing changes daily. Which of the following types of debridement should the nurse include in the plan of care?

• Enzymatic
• Surgical
• Autolytic
• Mechanical

• A nurse is caring for a female client who has toxic shock syndrome. Which of the following

findings should the nurse expect?

• Elevated platelet count
• Decreased total bilirubin
• Generalized rash
• Hypertension

• A nurse is preparing to administer a medication for a client through a non-tunneled

percutaneous central catheter. Which of the following actions should the nurse take?

• Close the inline clamp
• Apply a local anesthetic to the skin
• Don sterile gloves
• Flush the catheter with 10 mL of 0.9% sodium chloride

• A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel

obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?

• The client reports being extremely thirsty with a sore throat
• The drainage is bright green in color with brown fecal material
• The amount of drainage is gradually decreasing
• The client’s abdomen becomes distended and firm

• A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the

following findings should the nurse expect?

• Elevated blood pressure
• Hypothermia
• Urine specific gravity 1.001
• BUN 15 mg/dL

• A nurse is caring for a client who has hyperthyroidism and develops thyroid storm. Which of

the following instructions should the nurse give to the client regarding management of thyroid storm?

• You will need to begin taking an ACE inhibitor medication
• You will need a pacemaker to increase your heart rate