Adult Health Nursing
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Q1           Score:  1
 Administer Kayexalate 15 g orally.
 Administer spironolactone 25 mg orally.
 Assess WCG strip for tall T waves.
 Administer potassium 10 mEq orally.
Q2           Score:  1
 A client with fibromyalgia
 A client with phantom limb pain
 A client with progressive pancreatic cancer
 A client with trigeminal neuralgia
Q3           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
Q4           Score:  1
 Feet
 Neck
 Hands
 Sacrum
Q5           Score:  1
 Nasal congestion
 Nervousness
 Lethargy
 Hyperkalemia
Q6           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
Q7           Score:  1
 Leg movement
 Finger movement
 Lip movement
 Fighting the ventilator
Q8           Score:  1
 Acid-base balance
 Arterial Blood
 Arterial oxygen saturation
 Alveoli
Q9           Score:  1
 Draped
 Pulled
 Clipped
 Shampooed
Q10           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.
Q11           Score:  1
 Hypokalemia
 Hyperkalemia
 Hyponatremia
 Hypernatremia
Q12           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.
Q13           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
Q14           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
Q15           Score:  1
 Amitriptyline (Elavil)
 Corticosteroids
 Methylphenidate (Ritalin)
 Lorazepam (Ativan)
Q16           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.
Q17           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.
Q18           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.
Q19           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
Q20           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.
Q21           Score:  1
 Assess level of consciousness
 Verify patient identification and informed consent
 Assess vital signs
 Check for jewelry, gown, manicure and dentures
Q22           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
Q23           Score:  1
 Macaroni and cheese
 Shrimp with rice
 Turkey breast
 Spaghetti and meatballs
Q24           Score:  1
 check for presence underwear
 check for presence dentures
 check patient’s blood studies
 check baseline vital signs
Q25           Score:  1
 Nausea or vomiting
 Abdominal pain or diarrhea
 Hallucinations or tinnitus
 Lightheadedness or paresthesia
Q26           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.
Q27           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
Q28           Score:  1
 Weighing the client daily
 Measuring the extremity
 Measuring the intake and output
 Checking for pitting
Q29           Score:  1
 Aspartate aminotransferase
 Lactic acid dehydrogenase
 Hydroxybutyric dehydrogenase
 Creatine phosphokinase
Q30           Score:  1
 perioperative anxiety and stress
 delayed coagulation time
 delayed wound healing
 postoperative respiratory dysfunction
Q31           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.
Q32           Score:  1
 Patients with an acute asthma attack
 Patients with narcolepsy
 Patients under age 6
 Elderly patients
Q33           Score:  1
 Regular insulin
 Glipizide (Glucotrol)
 Repaglinide (Prandin)
 Metformin (Glucophage)
Q34           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
Q35           Score:  1
 Localized heat and redness
 Serosanguinous exudates and skin blanching
 Separation of the incision
 Blood clots and scar tissue are visible
Q36           Score:  1
 Utilize an infusion pump.
 Check the blood glucose level.
 Place the client in Trendelenburg position.
 Cover the solution with foil.
Q37           Score:  1
 Sodium
 Potassium
 Magnesium
 Calcium
Q38           Score:  1
 Question the order.
 Administer the medications.
 Administer them separately.
 Contact the pharmacy.
Q39           Score:  1
 Intraspinal
 Patient-controlled analgesia (PCA)
 Intravenous (IV)
 Sublingual
Q40           Score:  1
 Contralateral side in a simple pneumothorax
 Affected side in a hemothorax
 Affected side in a tension pneumothorax
 Contralateral side in hemothorax
Q41           Score:  1
 Therapeutic touch
 Use of heat and cold applications
 Meditation
 Transcutaneous electrical nerve stimulation (TENS
Q42           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
Q43           Score:  1
 Sensory
 Affective
 Sociocultural
 Behavioral
Q44           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
Q45           Score:  1
 Last case
 In between cases
 According to availability of anesthesiologist
 According to the surgeon’s preference
Q46           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
Q47           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
Q48           Score:  1
 Simple description pain intensity scale
 0-10 numeric pain scale
 Faces pain-rating scale
 McGill-Melzack pain questionnaire
Q49           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
Q50           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.
Q51           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.
Q52           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.
Q53           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
Q54           Score:  1
 Yellow
 Green
 Clear
 Gray
Q55           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
Q56           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


   



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