Advanced Adult Health Exam 1 practice Questions With Complete Solutions.
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Course
Collaborative Adult Health
Institution
Collaborative Adult Health
1. On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take?
a. Encourage the client to dri...
Advanced Adult Health Exam 1 practice
Questions With Complete Solutions.
1. On a hot humid day, an emergency department nurse is caring for a client who is confused and has
these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min,
blood pressure 106/66 mm Hg. Which action should the nurse take?
a. Encourage the client to drink cool water or sports drinks.
b. Start an intravenous line and infuse 0.9% saline solution.
c. Administer acetaminophen (Tylenol) 650 mg orally.
d. Encourage rest and re-assess in 15 minutes. - Answer ANS: B
The client demonstrates signs of heat stroke. This is a medical emergency and priority care includes
oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter, and aggressive
interventions to cool the client, including external cooling and internal cooling methods. Oral hydration
would not be appropriate for a client who has symptoms of heat stroke because oral fluids would not
provide necessary rapid rehydration, and the confused client would be at risk for aspiration.
Acetaminophen would not decrease this client's temperature or improve the client's symptoms. The
client needs immediate medical treatment; therefore, rest and re-assessing in 15 minutes is
inappropriate.
2. While at a public park, a nurse encounters a person immediately after a bee sting. The person's lips
are swollen, and wheezes are audible. Which action should the nurse take first?
a. Elevate the site and notify the person's next of kin.
b. Remove the stinger with tweezers and encourage rest.
c. Administer diphenhydramine (Benadryl) and apply ice.
d. Administer an EpiPen from the first aid kit and call 911. - Answer ANS: D
The client's swollen lips indicate that anaphylaxis may be developing, and this is a medical emergency.
911 should be called immediately, and the client transported to the emergency department as quickly as
possible. If an EpiPen is available, it should be administered at the first sign of an anaphylactic reaction.
The other answers do not provide adequate interventions to treat airway obstruction due to anaphylaxis.
3. A client presents to the emergency department after prolonged exposure to the cold. The client is
difficult to arouse and speech is incoherent. Which action should the nurse take first?
a. Reposition the client into a prone position.
, b. Administer warmed intravenous fluids to the client.
c. Wrap the client's extremities in warm blankets.
d. Initiate extracorporeal rewarming via hemodialysis. - Answer ANS: B
Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute
confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia should be treated
by core rewarming methods, which include administration of warm IV fluids, heated oxygen, and heated
peritoneal, pleural, gastric, or bladder lavage, and by positioning the client in a supine position to
prevent orthostatic changes. The client's trunk should be warmed prior to the extremities to prevent
peripheral vasodilation. Extracorporeal warming with cardiopulmonary bypass or hemodialysis is a
treatment for severe hypothermia.
4. An emergency department nurse cares for a middle-aged mountain climber who is confused and
exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse
implement?
a. Administer dexamethasone (Decadron).
b. Complete a mini-mental state examination.
c. Prepare the client for computed tomography of the brain.
d. Request a psychiatric consult. - Answer ANS: A
The client is exhibiting signs of mountain sickness and high altitude cerebral edema (HACE).
Dexamethasone (Decadron) reduces cerebral edema by acting as an anti-inflammatory in the central
nervous system. The other interventions will not treat mountain sickness or HACE.
5. An emergency department nurse assesses a client admitted after a lightning strike. Which assessment
should the nurse complete first?
a. Electrocardiogram (ECG)
b. Wound inspection
c. Creatinine kinase
d. Computed tomography of head - Answer ANS: A
Clients who survive an immediate lightning strike can have serious myocardial injury, which can be
manifested by ECG and myocardial perfusion abnormalities. The nurse should prioritize the ECG. Other
assessments should be completed but are not the priority.
6. A nurse teaches a community health class about water safety. Which statement by a participant
indicates that additional teaching is needed?
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