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Adult Health Nursing
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Right to left
Left to right
Q1
Score: 1
Yellow
Green
Clear
Gray
Q2
Score: 1
Weighing the client daily
Measuring the extremity
Measuring the intake and output
Checking for pitting
Q3
Score: 1
the surgeon greets his client before induction of anesthesia
the surgeon and anesthesiologist are in tandem
strap made of strong non-abrasive material are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board
client is monitored throughout the surgery by the assistant anesthesiologist
Q4
Score: 1
Sodium
Potassium
Magnesium
Calcium
Q5
Score: 1
Contralateral side in a simple pneumothorax
Affected side in a hemothorax
Affected side in a tension pneumothorax
Contralateral side in hemothorax
Q6
Score: 1
Assess the readiness of the client prior to surgery
Ensure that the airway is adequate
Account for the number of sponges, needles, supplies, Used during the surgical procedure
Evaluate the type of anesthesia appropriate for the surgical client
Q7
Score: 1
Put side rails up and ask client not to get out of bed
Send the client to ORD with the family
Allow client to get up to go to the comfort room
Obtain consent form
Q8
Score: 1
Question the order.
Administer the medications.
Administer them separately.
Contact the pharmacy.
Q9
Score: 1
Weight client every morning.
Maintain accurate intake and output.
Restrict fluid to 1500 mL per day.
Administer furosemide (Lasix) 40 mg IV push.
Q10
Score: 1
Replenish her supply every 3 months.
Take one every 15 minutes if pain occurs.
Leave the medication in the brown bottle.
Crush the medication and take it with water.
Q11
Score: 1
Serum potassium 5.2 mEq/L
Serum sodium 134 mEq/L
Serum calcium 10.6 mg/dL
Serum magnesium 0.8 mEq/L
Q12
Score: 1
Treatment is based on client goals.
A multidisciplinary approach is needed.
The client must be believed about perceptions of own pain.
Drug side effects must be prevented and managed.
Q13
Score: 1
Reassess the client’s blood pressure and heart rate
Review the client’s morning calcium level
Request a neurologic consult today
Check the client’s papillary reaction to light
Q14
Score: 1
Leg movement
Finger movement
Lip movement
Fighting the ventilator
Q15
Score: 1
The client reports pain reduction and decreased activity
The client denies existence of pain
The client can distract himself during pain episodes
The client reports independence from watchers
Q16
Score: 1
Activity intolerance related to fatigue
Anxiety related to actual threat to health status
Risk for infection related to retained secretions
Impaired gas exchange related to airflow obstruction
Q17
Score: 1
Amitriptyline (Elavil)
Corticosteroids
Methylphenidate (Ritalin)
Lorazepam (Ativan)
Q18
Score: 1
I will call my doctor if I experience muscle twitching or seizures.
I will make sure to take my vitamin D with my calcium each day.
I will take my calcium pill every morning before breakfast.
I will avoid dairy products, broccoli, and spinach when I eat.
Q19
Score: 1
Macaroni and cheese
Shrimp with rice
Turkey breast
Spaghetti and meatballs
Q20
Score: 1
The client’s low phosphorus is probably due to malnutrition.
The client is just worn out form not getting enough rest.
The client’s skeletal muscles are weak because of the low phosphorus.
The client will do more for herself when her phosphorus is normal.
Q21
Score: 1
Bilateral inspiratory and expiratory crackles
Absence of breaths sound in the right thorax
Inspiratory wheezes in the right thorax
Bilateral pleural friction rub
Q22
Score: 1
Administer smallest dose that provides relief with the fewest side effects.
Titrate upward until the client is pain free.
Titrate downwards to prevent toxicity.
Ensure that the drug is adequate to meet the client’s subjective needs.
Q23
Score: 1
Make a note in the nurse’s file and continue to observe clinical performance.
Refer the new nurse to the in-service education department.
Quiz the nurse about knowledge of pain management.
Give praise for the correct dose and time and discuss the deficits in charting.
Q24
Score: 1
Draped
Pulled
Clipped
Shampooed
Q25
Score: 1
Acid-base balance
Arterial Blood
Arterial oxygen saturation
Alveoli
Q26
Score: 1
Kinking of the ventilator tubing
A disconnected ventilator tube
An endotracheal cuff leak
A change in the oxygen concentration without resetting the oxygen level alarm
Q27
Score: 1
check for presence underwear
check for presence dentures
check patient’s blood studies
check baseline vital signs
Q28
Score: 1
Explain all the possible interventions that may cause the client to worry.
Establish trusting relationship by giving his medication on time.
Stay with the client during pain episodes.
Promote client’s sense of control and participation in pain control by listening to his concerns.
Q29
Score: 1
Last case
In between cases
According to availability of anesthesiologist
According to the surgeon’s preference
Q30
Score: 1
Hypokalemia
Hyperkalemia
Hyponatremia
Hypernatremia
Q31
Score: 1
Patients with an acute asthma attack
Patients with narcolepsy
Patients under age 6
Elderly patients
Q32
Score: 1
Encourage oral feeding as soon as possible
Develop an alternative communication method
Keep the tracheostomy cuff fully inflated
Keep the patient flat in bed
Q33
Score: 1
Nasal congestion
Nervousness
Lethargy
Hyperkalemia
Q34
Score: 1
Check the MARs and nurses’ notes for the past several days.
Ask the nurse educator to give an in-service about pain management.
Perform a complete pain assessment and history on the client.
Have a conference with the nurses responsible for the care of this client.
Q35
Score: 1
Simple description pain intensity scale
0-10 numeric pain scale
Faces pain-rating scale
McGill-Melzack pain questionnaire
Q36
Score: 1
Dressing is intact but partially soiled
Left foot is cold to touch and pedal pulse is absent
Left leg in limited functional anatomic position
BP 114/78, pulse of 82 beats/minute
Q37
Score: 1
A client with fibromyalgia
A client with phantom limb pain
A client with progressive pancreatic cancer
A client with trigeminal neuralgia
Q38
Score: 1
Localized heat and redness
Serosanguinous exudates and skin blanching
Separation of the incision
Blood clots and scar tissue are visible
Q39
Score: 1
Report muscle weakness to the physician.
Allow 6 months for the drug to take effect.
Take the medication with fruit juice.
Ask the doctor to perform a complete blood count prior to starting the medication.
Q40
Score: 1
Sensory
Affective
Sociocultural
Behavioral
Q41
Score: 1
Feet
Neck
Hands
Sacrum
Q42
Score: 1
Instruct client to observe strict bed rest
Check for epidural catheter drainage
Administer analgesia through epidural catheter as prescribed
Assess respiratory rate carefully
Q43
Score: 1
Administer IV fluids as prescribed by the physician.
Provide straws and offer fluids between meals.
Develop plan for added fluid intake over 24 hours.
Teach family members to assist client with fluid intake.
Q44
Score: 1
Utilize an infusion pump.
Check the blood glucose level.
Place the client in Trendelenburg position.
Cover the solution with foil.
Q45
Score: 1
Monitor fluctuations in the water-seal chamber
Clamp the chest tube once every shift
Encourage coughing and deep breathing
Milk the chest tube every 2 hours
Q46
Score: 1
perioperative anxiety and stress
delayed coagulation time
delayed wound healing
postoperative respiratory dysfunction
Q47
Score: 1
Provide oral care every 3-4 hours
Monitor for indications of dehydration
Administer 0.45% saline by IV line
Assess daily weights for trends
Q48
Score: 1
Flattened neck veins when client is in supine position
Full and bounding pedal and post-tibial pulses
Pitting edema located in feet, ankles, and calves
Shallow respirations with crackles on auscultation
Q49
Score: 1
Nausea or vomiting
Abdominal pain or diarrhea
Hallucinations or tinnitus
Lightheadedness or paresthesia
Q50
Score: 1
Aspartate aminotransferase
Lactic acid dehydrogenase
Hydroxybutyric dehydrogenase
Creatine phosphokinase
Q51
Score: 1
Assess level of consciousness
Verify patient identification and informed consent
Assess vital signs
Check for jewelry, gown, manicure and dentures
Q52
Score: 1
Intraspinal
Patient-controlled analgesia (PCA)
Intravenous (IV)
Sublingual
Q53
Score: 1
Observe the dressing and type and odor of drainage if any
Get patient’s consent
Wash hands
Request the client to expose the incision wound
Q54
Score: 1
Administer Kayexalate 15 g orally.
Administer spironolactone 25 mg orally.
Assess WCG strip for tall T waves.
Administer potassium 10 mEq orally.
Q55
Score: 1
Regular insulin
Glipizide (Glucotrol)
Repaglinide (Prandin)
Metformin (Glucophage)
Q56
Score: 1
Therapeutic touch
Use of heat and cold applications
Meditation
Transcutaneous electrical nerve stimulation (TENS
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