Adult Health Nursing Answer Key

Adult Health Nursing Answer Key Related

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A nurse is preparing to assist with a transurethral resection of the prostate (TURP) procedure for a patient with benign prostatic hyperplasia (BPH). What action should the nurse prioritize to prevent fluid overload during TURP?

  • A. Monitoring the patient's serum electrolyte levels during the procedure
  • B. Administering diuretic medications to the patient before the procedure
  • C. Limiting the duration of irrigation fluid instillation during TURP
  • D. Adjusting the irrigation fluid temperature to promote hemostasis
Correct Answer: C

Rationale: During a transurethral resection of the prostate (TURP), fluid irrigation is commonly used to distend the bladder and flush out tissue debris. However, it is important to prioritize preventing fluid overload in the patient. Limiting the duration of irrigation fluid instillation is a crucial action to prevent excessive fluid absorption and subsequent fluid overload. Prolonged irrigation may lead to an increased risk of fluid overload and electrolyte imbalances, which can result in serious complications such as hyponatremia and fluid volume excess. Monitoring the patient's serum electrolyte levels can be important, but limiting the duration of irrigation is a more immediate and proactive measure to prevent fluid overload. Administering diuretic medications before the procedure may not be appropriate without assessing the patient's specific fluid status and needs. Adjusting the irrigation fluid temperature, while important for hemostasis, does not directly

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When conducting a nursing history on the Health Perception, Health Management pattern of functioning what is the APPROPRIATE question to be asked pre-operatively?

  • A. Do you experience your wound to heal quickly?
  • B. Do you have shortness of breath when exercising?
  • C. Are you aware of risk factors for your disease?
  • D. Have you experience weight changes in the past?
Correct Answer: C

Rationale: When conducting a nursing history on the Health Perception, Health Management pattern of functioning pre-operatively, an appropriate question to ask would be "Are you aware of risk factors for your disease?" This question helps assess the individual's level of awareness and understanding of their health condition and the factors that may impact it. Understanding the patient's knowledge of their risk factors can help guide interventions and education before surgery to optimize their health outcomes. Asking about perceived wound healing, shortness of breath, or weight changes may not be directly related to the patient's awareness of their disease risk factors in the pre-operative setting.

In order not to frighten small children, it is best to examine things that are uncomfortable or frightening to them last so as not to lose their cooperation. This means the LAST thing to do in a child is, which of the following, EXCEPT________.

  • A. Inspection of the throat with a throat stick.
  • B. Inspection of the ears with an otoscope
  • C. Auscultation of the heart
  • D. Undressing the child
Correct Answer: C

Rationale: When examining a child, especially one who may already be feeling scared or uncomfortable, it is important to prioritize the order of procedures to help maintain their cooperation and reduce their anxiety. Undressing the child is typically done first to ensure a thorough examination can be performed, and it is a less invasive procedure compared to others. Inspection of the throat with a throat stick and inspection of the ears with an otoscope are common procedures that may cause mild discomfort but are often tolerated well by children. Auscultation of the heart is usually done after these initial steps and is not typically as uncomfortable or frightening for children compared to other procedures. Therefore, auscultation of the heart should not be the last thing to do when examining a child to avoid frightening them.

The staff assigned to check the fire extinguisher failed to monitor the assigned equipment. The following statements are "whereabouts" of true, EXCEPT

  • A. all employees are lazy
  • B. monitoring staff is important
  • C. not all staff are diligent in their tasks
  • D. two errors added together can be potentially devastating
Correct Answer: A

Rationale: The statement "all employees are lazy " is not a correct assertion. It is a generalization that is unfair to make about all employees. It is incorrect to assume that all employees are lazy based on the failure of a certain staff member to monitor the fire extinguisher. Making blanket statements like this can lead to further misunderstandings and negativity in the workplace. The focus should be on individual accountability, proper training, and clear communication to ensure that tasks are being diligently carried out.

A 70- year-old has been rushed to the hospital due to bradycardia and palpitation. The physician suggested that a pacemaker be inserted to correct the symptoms. The patient voluntarily decides not to have the pacemaker Inserted. This is respected by the family. This is an example of what ethical principles

  • A. Beneficence
  • B. Autonomy
  • C. Fidelity
  • D. Justice
Correct Answer: B

Rationale: Autonomy is the ethical principle that respects an individual's right to make their own decisions about their medical treatment, even if it goes against medical advice or the preferences of others. In this case, the 70-year-old patient has voluntarily decided not to have the pacemaker inserted despite the physician's recommendation. The fact that the patient's decision is respected by the family reflects the importance of honoring the patient's autonomy and right to make decisions about their own healthcare.

The female client who is very anxious and fidgety is blowing off to much carbon dioxide develops tingling sensation of the lips and fingers and is not able to control her respirations. The MOST appropriate nursing intervention for this client is to _____.

  • A. Instruct the client to blow her nose and take deep breath
  • B. Administer oxygen
  • C. Have the client breath into a paper bag
  • D. Administer IV fluids as ordered
Correct Answer: C

Rationale: The client is experiencing symptoms of hyperventilation, a condition that occurs when there is excessive elimination of carbon dioxide from the body. Breathing into a paper bag can help by allowing the client to rebreathe carbon dioxide, which can help restore the balance of gases in the blood and alleviate the tingling sensations in the lips and fingers. This technique is commonly used to help regulate breathing in cases of hyperventilation. Administering oxygen (choice B) may not be necessary as the issue lies with an imbalance of carbon dioxide, not a lack of oxygen. Instructing the client to blow her nose and take deep breaths (choice A) may not address the underlying problem effectively. Administering IV fluids (choice D) is not relevant to the client's symptoms of hyperventilation.

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