ADULT HEALTH 2 EXAM -REVISION GUIDE 1. The nurse assists the provider with a liver biopsy at the bedside. Which position does the nurse put the patient in
... [Show More] 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 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 headache 6. 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 levels Prevention 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 9.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 10. 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 11.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. 12.. 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 13. 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 14. 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. 15.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 16.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 17.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 18.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. 19.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 20.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. 21.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 22.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 23.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. 24.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 25.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 motion B) Signs of systemic infection C) Joint stiffness, especially in the morning D) Visible atrophy of the knee and shoulder joints 26.. 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. 27.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. 28.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 A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A) Asterixis: tremor of the hands involuntary B) Constructional apraxia C) Fetor hepaticus D) Palmar erythema 45.A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? A) Finish all prescribed courses of antibiotics, regardless of symptom resolution. B) Adhere to dosing recommendations of OTC analgesics. C) Ensure that expired medications are disposed of safely. D) Ensure that pharmacists regularly review drug regimens for potential interactions. 46.A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A) Keep patient NPO until the results of test are known. B) Keep patient NPO until the patient’s gag reflex returns. C) Administer analgesia until post-procedure tenderness is relieved. D) Give the patient a cold beverage to promote swallowing ability. 47.A group of nurses have attended an in service on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse’s risk of acquiring hepatitis C in the workplace? A) Disposing of sharps appropriately and not recapping needles B) Performing meticulous hand hygiene at the appropriate moments in care C) Adhering to the recommended schedule of immunizations D) Wearing an N95 mask when providing care for patients on airborne precautions 48.A hospital patient is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test? A) Arrange for a portable x-ray machine to be used. B) Have the patient wear a mask to the x-ray department. C) Ensure that the radiology department has been disinfected prior to the test. Send the patient to the x-ray department, and have the staff in the department wear D) masks. 49.A patient has been diagnosed with AIDS complicated by chronic diarrhea. What nursing intervention would be appropriate for this patient? A) Position the patient in the high Fowler’s position whenever possible. B) Temporarily eliminate animal protein from the patient’s diet. C) Make sure the patient eats at least two servings of raw fruit each day. D) Obtain a stool culture to identify possible pathogens. 50.A nurse is performing the admission assessment of a patient who has AIDS. What components should the nurse include in this comprehensive assessment? Select all that apply. Current medication regimen Identification of patient’s support system Immune system function Genetic risk factors for HIV History of sexual practices 51.A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following? A) Hydromorphone (Dilaudid) B) Methotrexate (Rheumatrex) C) Allopurinol (Zyloprim) D) Prednisone 52.A community health nurse is performing a visit to the home of a patient who has a history of rheumatoid arthritis (RA). On what aspect of the patient’s health should the nurse focus most closely during the visit? A) The patient’s understanding of rheumatoid arthritis B) The patient’s risk for cardiopulmonary complications C) The patient’s social support system D) The patient’s functional status 53.The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A) Stable vital signs and ABGs B) Pulse oximetry above 80% and stable vital signs C) Stable nutritional status and ABGs D) Normal orientation and level of consciousness 54.The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A) 20 cm H2O B) 15 cm H2O C) 10 cm H2O D) 5 cm H2O 55.A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2 D) CNS disturbances 56.You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results? A) Respiratory acidosis with no compensation B) Metabolic alkalosis with a compensatory alkalosis C) Metabolic acidosis with no compensation D) Metabolic acidosis with a compensatory respiratory alkalosis 57.A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? Respiratory acidosis Metabolic alkalosis Respiratory alkalosis Metabolic acidosis 58.The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A) Fluid intake for the last 24 hours B) Baseline arterial blood gas (ABG) levels C) Prior outcomes of weaning D) Electrocardiogram (ECG) results 59.A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe? A) It allows for full expansion of the lungs within the thoracic cavity. B) It prevents the lungs from collapsing within the thoracic cavity. C) It limits lung expansion within the thoracic cavity. D) It lubricates the movement of the thorax and lungs. 60.A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample? A) Immediately after a meal B) First thing in the morning C) At bedtime D) After a period of exercise The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what? A) Pleurisy B) Emphysema C) Asthma D) Pneumonia 62.The nurse has assessed a patient’s family history for three generations. The presence of which respiratory disease would justify this type of assessment? A) Asthma B) Obstructive sleep apnea C) Community-acquired pneumonia D) Pulmonary edema 63.The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? A) Cognition is decreased. B) Daily arterial blood gases (ABGs) are necessary. C) Slight tracheal bleeding is anticipated. D) The cough reflex is depressed. 64.The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? A) Keep the patient in a low Fowler’s position. B) Perform tracheostomy care at least once per day. C) Maintain continuous bedrest. D) Monitor cuff pressure every 8 hours. The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning 65. preoperative teaching, what information should the nurse communicate to the patient? A) How to milk the chest tubing B) How to splint the incision when coughing C) How to take prophylactic antibiotics correctly D) How to manage the need for fluid restriction The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is 66. aware that the weaning of the patient will progress in what order? A) Removal from the ventilator, tube, and then oxygen B) Removal from oxygen, ventilator, and then tube C) Removal of the tube, oxygen, and then ventilator D) Removal from oxygen, tube, and then ventilator 67.The nurse is performing patient education for a patient who is being discharged on mini- nebulizer treatments. What information should the nurse prioritize in the patient’s discharge teaching? A) How to count her respirations accurately B) How to collect serial sputum samples C) How to independently wean herself from treatment D) How to perform diaphragmatic breathing 68.The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? A) Between 10 and 15 mm Hg B) Between 15 and 20 mm Hg C) Between 20 and 25 mm Hg D) Between 25 and 30 mm Hg 69.A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? A) Correct use of a ventilator B) Correct use of incentive spirometry C) Correct use of a mini-nebulizer D) Correct technique for rhythmic breathing 70.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 client’s 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? Diminished or absent breath sounds on the A) affected side Paradoxical chest wall movement with B) respirations C) Sudden loss of consciousness D) Muffled heart sounds 71.The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patient’s symptoms from those of a cardiac etiology? A) Carboxyhemoglobin level B) Brain natriuretic peptide (BNP) level C) C-reactive protein (CRP) level D) Complete blood count 72.A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures are initiated in a patient with ARDS? A) Psychological counseling B) Nutritional support C) High-protein oral diet D) Occupational therapy 73.A nurse is planning the care of a patient who has a long history of chronic pain, which has only recently been diagnosed as fibromyalgia. What nursing diagnosis is most likely to apply to this woman’s care needs? A) Ineffective Role Performance Related to Pain Risk for Impaired Skin Integrity Related to B) Myalgia C) Risk for Infection Related to Tissue Alterations D) Unilateral Neglect Related to Neuropathic Pain 74.A patient with an exacerbation of systemic lupus erythematosus (SLE) has been hospitalized on the medical unit. The nurse observes that the patient expresses angerand irritation when her call bell isn’t answered immediately. What would be the most appropriate response? “You seem like you’re feeling angry. Is that A) something that we could talk about?” “Try to remember that stress can make your B) symptoms worse.” C) “Would you like to talk about the problem with the nursing supervisor?” “I can see you’re angry. I’ll come back when D) you’ve calmed down.” 75.A community health nurse is performing a visit to the home of a patient who has a history of rheumatoid arthritis (RA). On what aspect of the patient’s health should the nurse focus most closely during the visit? The patient’s understanding of rheumatoid A) arthritis The patient’s risk for cardiopulmonary B) complications C) The patient’s social support system D) The patient’s functional status 76.A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority? A) Oral temperature of 100°F B) Tachypnea and restlessness C) Frequent loose stools D) Weight loss of 1 pound since yesterday 77.A patient was tested for HIV using enzyme immunoassay (EIA) and results were positive. The nurse should expect the primary care provider to order what test to confirm the EIA test results? A) Another EIA test B) Viral load test C) Western blot test D) CD4/CD8 ratio 78.A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing intervention best addresses this risk? A) Utilize a pressure-reducing mattress. B) Limit the patient’s physical activity. Apply antibiotic ointment to dependent skin C) surfaces. D) Avoid contact with synthetic fabrics. CONTINUED...DOWNLOAD FOR MORE REVISION TO THE BEST SCORES [Show Less]