Adult Health 2 Study Guide

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Sample questions from Adult Health 2 Study Guide

This material has 20 questions with answers and rationales. Here are the first 5.

1. 1.A client admitted with pneumonia becomes confused. Respirations are 32/min, blood pressure is 88/50 mm Hg, and urine output is 10 mL during the past hour. Which action should the RN take first?

   • A.Activate rapid response while assessing and supporting airway, breathing, and circulation.
   • B.Ask assistive personnel to repeat the assessment in one hour.
   • C.Wait for the next scheduled laboratory results.
   • D.Begin discharge teaching about pneumonia prevention.

   Rationale: B is correct because the client has acute respiratory and perfusion deterioration requiring immediate help and supportive assessment. A is inappropriate during instability. C delays treatment for possible shock. D improperly delays care and delegates assessment of an unstable client.

2. 2.A client with suspected acute coronary syndrome has an oxygen saturation of 97% on room air and no respiratory distress. Which action is the priority?

   • A.Apply oxygen at 6 L/min routinely.
   • B.Encourage walking to determine exercise tolerance.
   • C.Wait until troponin is elevated before initiating monitoring.
   • D.Obtain a 12-lead ECG promptly.

   Rationale: C is correct because rapid ECG acquisition identifies ischemic patterns and guides time-sensitive treatment. A is not routinely indicated in a normoxemic client. B increases myocardial demand. D is unsafe because early troponin may be normal and monitoring should not await elevation.

3. 3.Before administering prescribed nitroglycerin for chest pain, which finding requires the nurse to withhold it and notify the prescriber?

   • A.The client rates pain as 8 out of 10.
   • B.The client has a history of hyperlipidemia.
   • C.The client took sildenafil two hours ago.
   • D.The heart rate is 92/min.

   Rationale: A is correct because recent sildenafil combined with nitrates can cause profound hypotension. B supports the need for prompt evaluation and appropriate treatment but is not a contraindication. C is not independently a hold indication. D is a coronary risk factor, not a reason to withhold nitroglycerin.

4. 4.A monitored client becomes unresponsive. The nurse confirms no pulse, and the rhythm is ventricular fibrillation. Which treatment is indicated?

   • A.Atropine followed by observation.
   • B.Immediate CPR and prompt defibrillation.
   • C.Synchronized cardioversion after a full history.
   • D.Adenosine through a peripheral IV.

   Answer and rationale are in the full material.

5. 5.A client with heart failure suddenly develops severe dyspnea, diffuse crackles, and an oxygen saturation of 82%. Which action should the nurse take first?

   • A.Place the client flat with the legs elevated.
   • B.Delay intervention until a daily weight is obtained.
   • C.Encourage the client to drink water.
   • D.Position upright if tolerated, provide oxygen, and summon urgent assistance.

   Answer and rationale are in the full material.