Adult Health 2 EXAM II Correct Answers Provided.
Adult Health 2 EXAM II
1. Patient on PEEP (believe) experiencing ARDS (select all that apply)
a.
... [Show More] Beta blocker
b. Loop diuretic
c. Bronchodilator
d. Something else corticosterian
Look it up
1. The nurse assists the provider with a liver biopsy at the bedside. Which position does the nurse put the
patient in after the biopsy?
Supine with head elevated on one pillow
Semi-fowlers with two pillows under the leg
Right side lying with a folded towel under the puncture site
Left side lying with a small pillow under the puncture site
2. A patient is hospitalized for severe anorexia, fatigue, mild jaundice, hepatomegaly, and abnormal liver
function tests. The physician suspects viral hepatitis. In planning care, which patient outcome does the
nurse assign the highest priority?
Maintains adequate nutrition
Maintains usual exercise regimen
Adapts to changes in appearance
Definitely identifies source of exposure to hepatitis virus
3. Select all the potential causes for hepatic inflammation (double check this answer)
Virus
Penicillin
Acetaminophen
Alcohol
Chocolate
4. A patient admitted to the hospital with a diagnosis of cirrhosis has a massive ascites’s and difficulty
breathing. The nurse performers which intervention as a priority measure to assist the patient with
breathing?
Reposition side to side every 2 hours
Auscultate the lung sounds every 4hours
Encourage deep breathing exercises
Elevate the head of the bed 60 degrees
5. A home health nurse visits a patient who was recently diagnosed with cirrhosis and provides home care
management instructions to the patient. Which statement by the patient indicates the need for further
instructions?
I will obtain adequate rest
I should monitor my weight regularly
I should include sufficient carbs in my diet
I will take acetaminophen (Tylenol) if I get a headache6. The nurse administers lactulose to a patient with cirrhosis the patient complains of diarrhea. The nurse
explains that it is important to take the drug for which effect?
Prevention of constipation
Promotion of fluid loss
Reduction in serum ammonia levelsPrevention of gastrointestinal bleeding
7. A patient with liver cancer has severe ascites and shortness of breath. The physician plans a paracentesis.
The nurse prepares the patient for the paracentesis with which action?
Have client empty bladder
Position patient flat on right side
Have them lie flat with a small pillow under the small of his back
Sedate the client with versed
8. The patient is admitted to the ED with vomiting of bright red blood. Which info is most important for the
nurse to obtain during assessment?
Vital signs and symptoms of hypovolemia
History of prior bleeding
Medication client is taking
Current medical problems
21. (WORDED DIFFERENTLY ON TEST): A nurse is educating a patient in anticipation of
a procedure that will require a water-sealed chest drainage system. What should the
nurse tell the patient and the family that this drainage system is used for?
A) Maintaining positive chest-wall pressure
B) Monitoring pleural fluid osmolarity
C) Providing positive intrathoracic pressure
D) Removing excess air and fluid
22. (WORDED DIFFERENTLY ON TEST): A patient is exhibiting signs of a pneumothorax
following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall.
What should the nurse tell the family is the primary purpose of this chest tube?
A) To remove air from the pleural space
B) To drain copious sputum secretions
C) To monitor bleeding around the lungs
D) To assist with mechanical ventilation
23.While assessing the patient, the nurse observes constant bubbling in the water-seal
chamber of the patients closed chest-drainage system. What should the nurse conclude?
The system is functioning normally.
The patient has a pneumothorax.
The system has an air leak.
The chest tube is obstructed.25. The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis
of lung cancer. While assisting with a subclavian vein central line insertion, the nurse
notes the clients oxygen saturation rapidly dropping. The patient complains of
shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax
has developed. Further assessment findings supporting the presence of a
pneumothorax include what?
A) Diminished or absent breath sounds on the affected side
B) Paradoxical chest wall movement with respirations
C) Sudden loss of consciousness
D) Muffled heart sounds
27. The nurse at a long-term care facility is assessing each of the residents. Which resident
most likely faces the greatest risk for aspiration?
70 Years old man who aspirated before
A resident with mid-stage Alzheimers disease
A 92-year-old resident who needs extensive help with ADLs
A resident with severe and deforming rheumatoid arthritis
30. The nurse is addressing condom use in the context of a health promotion
workshop. When discussing the correct use of condoms, what should the nurse tell
the attendees?
A) Attach the condom prior to erection.
B) A condom may be reused with the same partner if ejaculation has not occurred.
C) Use skin lotion as a lubricant if alternatives are unavailable.
D) Hold the condom by the cuff upon withdrawal.
31.A nurse is working with a patient who was diagnosed with HIV several months
earlier. The nurse should recognize that a patient with HIV is considered to have AIDS
at the point when the CD4+ T-lymphocyte cell count drops below what threshold?
A) 75 cells/mm3 of blood
B) 200 cells/mm3 of blood
C) 325 cells/mm3 of blood
D) 450 cells/mm3 of blood
32. A nurse is performing an admission assessment on a patient with stage 3 HIV.
After assessing the patients gastrointestinal system and analyzing the data, what is
most likely to be the priority nursing diagnosis?A) Acute Abdominal Pain
B) Diarrhea
C) Bowel Incontinence
D) Constipation
33. The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of
Risk for Impaired Skin Integrity Related to Candidiasis. What nursing intervention best
addresses this risk?
A) Providing thorough oral care before and after meals
B) Administering prophylactic antibiotics
C) Promoting nutrition and adequate fluid intake
D) Applying skin emollients as needed
34. A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the
teen what she needs and the teen responds that she has become sexually active and
is concerned about getting HIV. The teen asks the nurse what she can do keep from
getting HIV. What would be the nurses best response?
A) Theres no way to be sure you wont get HIV except to use condoms correctly.
B) Only the correct use of a female condom protects against the transmission of
HIV.
C) There are new ways of protecting yourself from HIV that are being discovered
every day.
D) Other than abstinence, only the consistent and correct use of condoms is
effective in preventing HIV.
35. A patient is beginning an antiretroviral drug regimen shortly after being diagnosed
with HIV. What nursing action is most likely to increase the likelihood of successful
therapy?
A) Promoting appropriate use of complementary therapies
B) Addressing possible barriers to adherence
C) Educating the patient about the pathophysiology of HIV
D) Teaching the patient about the need for follow-up blood work
36. The nurse is caring for a patient who has been admitted for the treatment of AIDS.
In the morning, the patient tells the nurse that he experienced night sweats and
recently coughed up some blood. What is the nurses most appropriate action?
A) Assess the patient for additional signs and symptoms of Kaposis sarcoma.
B) Review the patients most recent viral load and CD4+ count.
C) Place the patient on respiratory isolation and inform the physician.D) Perform oral suctioning to reduce the patients risk for aspiration.
37. A patient with AIDS is admitted to the hospital with AIDS-related wasting
syndrome and AIDS-related anorexia. What drug has been found to promote
significant weight gain in AIDS patients by increasing body fat stores?
A) Advera
B) Momordicacharantia
C) Megestrol (Exam said MEGACE)
D) Ranitidine
39. A nurse is assessing the skin integrity of a patient who has AIDS. When performing
this inspection, the nurse should prioritize assessment of what skin surfaces?
A) Perianal region and oral mucosa
B) Sacral region and lower abdomen
C) Scalp and skin over the scapulae
D) Axillae and upper thorax
40. A hospital nurse has experienced percutaneous exposure to an HIV-positive
patients blood as a result of a needle stick injury. The nurse has informed the
supervisor and identified the patient. What action should the nurse take next?
A) Flush the wound site with chlorhexidine.
B) Report to the emergency department or employee health department.
C) Apply a hydrocolloid dressing to the wound site.
D) Follow up with the nurses primary care provider.
42. A nurse is performing the initial assessment of a patient who has a recent
diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the
nurse expect to observe on inspection?
A) Petechiae
B) Butterfly rash
C) Jaundice
D) Skin sloughing
43. A nurse is performing the health history and physical assessment of a patient who
has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most
consistent with the clinical presentation of RA?
A) Cool joints with decreased range of motionB) Signs of systemic infection
C) Joint stiffness, especially in the morning
D) Visible atrophy of the knee and shoulder joints
45. A patient with systemic lupus erythematosus (SLE) is preparing for discharge. The
nurse knows that the patient has understood health education when the patient
makes what statement?
A) Ill make sure I get enough exposure to sunlight to keep up my vitamin D levels.
B) Ill try to be as physically active as possible between flare-ups.
C) Avoid prolonged exposure to the sun
D) Ill stop taking my steroids when I get relief from my symptoms.
A clinic nurse is caring for a patient diagnosed with rheumatoid arthritis (RA).
The patient tells the nurse that she has not been taking her medication because
she usually cannot remove the childproof medication lids. How can the nurse
best facilitate the patients adherence to her medication regimen?
A) Encourage the patient to store the bottles with their tops removed.
B) Have a trusted family member take over the management of the patients
medication regimen.
C) Encourage her to have her pharmacy replace the tops with alternatives that
are easier to open.
D) Have the patient approach her primary care provider to explore medication
alternatives.
49. A nurses plan of care for a patient with rheumatoid arthritis includes several
exercise-based interventions. Exercises for patients with rheumatoid disorders should
have which of the following goals?
A) Maximize range of motion while minimizing exertion
B) Increase joint size and strength
C) Limit energy output in order to preserve strength for healing
D) Preserve and increase range of motion while limiting joint stress
50. 2 given ABGs and STAT what it is ?51. pulmonary edema = pink frothy sputum [Show Less]