Adult Health Nursing Test Banks

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A nurse is preparing to perform an intracranial pressure (ICP) monitoring procedure for a patient with traumatic brain injury. What action should the nurse prioritize to ensure procedural accuracy?

  • A. Ensuring proper zeroing and calibration of the ICP monitoring system
  • B. Positioning the patient in a high-Fowler's position during the procedure
  • C. Administering prophylactic antibiotics to prevent infection
  • D. Placing the ICP monitor in the subarachnoid space via lumbar puncture
Correct Answer: A

Rationale: The nurse should prioritize ensuring proper zeroing and calibration of the ICP monitoring system to ensure procedural accuracy and reliability of the measurements obtained. Proper zeroing involves setting the transducer at the level of the patient's external auditory meatus (ear), which serves as a reference point for accurate ICP readings. Calibration is necessary to establish accurate pressure measurements. Incorrect zeroing or calibration can lead to inaccurate ICP readings, which can impact clinical decision-making for patients with traumatic brain injury. Positioning the patient in a high-Fowler's position, administering prophylactic antibiotics, or placing the ICP monitor in the subarachnoid space via lumbar puncture are not directly related to ensuring the accuracy of the ICP monitoring procedure.

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Which of the following interventions is recommended for managing a patient with a suspected opioid overdose?

  • A. Administering naloxone intravenously.
  • B. Providing respiratory support with bag-valve-mask ventilation.
  • C. Encouraging the patient to drink fluids rapidly.
  • D. Administering benzodiazepines for sedation.
Correct Answer: A

Rationale: Naloxone is a medication used to reverse the effects of an opioid overdose by binding to opioid receptors and displacing the opioids. Administering naloxone intravenously is the recommended intervention for managing a patient with a suspected opioid overdose as it can quickly reverse respiratory depression, sedation, and other effects of opioids. This intervention can be life-saving in cases of opioid overdose and is a critical step in the management of such patients. Providing respiratory support with bag-valve-mask ventilation may be necessary in addition to naloxone administration to ensure adequate oxygenation, but naloxone remains the primary intervention to reverse the effects of opioids. Encouraging the patient to drink fluids rapidly or administering benzodiazepines for sedation are not recommended interventions for managing a suspected opioid overdose.

Which of the following conditions is characterized by an imbalance between bone resorption and formation, resulting in bone thinning and increased risk of fractures?

  • A. Osteoarthritis
  • B. Osteomyelitis
  • C. Osteoporosis
  • D. Osteomalacia
Correct Answer: C

Rationale: Osteoporosis is a condition characterized by an imbalance between bone resorption (breakdown of bone tissue) and bone formation, leading to bone thinning and increased risk of fractures. In osteoporosis, bones become weak and porous, making them more prone to fractures even with minor trauma. This condition is common in postmenopausal women and older individuals. Risk factors for osteoporosis include age, gender, family history, lack of physical activity, low calcium and vitamin D intake, smoking, excessive alcohol consumption, and certain medications. Treatment typically involves lifestyle modifications, including adequate calcium and vitamin D intake, weight-bearing exercises, and sometimes medication to help slow down bone loss and reduce fracture risk. Early detection and management of osteoporosis are crucial to prevent fractures and maintain bone health.

A patient with a history of chronic kidney disease is prescribed a low-phosphorus diet. Which dietary choice indicates understanding of the prescribed diet?

  • A. Grilled chicken breast
  • B. Cheese omelet
  • C. Whole wheat toast with peanut butter
  • D. Spinach salad with almonds
Correct Answer: A

Rationale: Grilled chicken breast is a suitable choice for a low-phosphorus diet because poultry is typically lower in phosphorus compared to dairy products (like cheese), nuts (like almonds), and whole grains (like wheat toast). This option indicates an understanding of the need to restrict phosphorus intake, which is important for individuals with chronic kidney disease to prevent complications.

and tumor necrosis factor-alpha (TNF-α) during the acute phase response?

  • A. Macrophages
  • B. T lymphocytes
  • C. B lymphocytes
  • D. Natural killer (NK) cells
Correct Answer: A

Rationale: Macrophages are the primary cells responsible for producing tumor necrosis factor-alpha (TNF-α) during the acute phase response. TNF-α is a pro-inflammatory cytokine that plays a critical role in initiating and propagating the inflammatory response. Macrophages secrete TNF-α in response to infection, injury, or other inflammatory stimuli, contributing to the recruitment of immune cells and the activation of additional inflammatory pathways. In the context of the acute phase response, macrophages are key mediators of the immune response and play a crucial role in host defense mechanisms.

Which of the following interventions is most appropriate for a patient with a tension pneumothorax?

  • A. Needle decompression
  • B. Chest tube insertion
  • C. High-flow oxygen therapy
  • D. Incentive spirometry
Correct Answer: A

Rationale: A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, causing increased pressure in the chest cavity. This can lead to compression of the lung and major blood vessels, leading to inadequate oxygenation and circulation.

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