Adult Health Nursing Answer Key

Adult Health Nursing Answer Key Related

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A patient is prescribed an opioid analgesic for postoperative pain management. Which nursing intervention is essential for preventing respiratory depression in the patient?

  • A. Administering naloxone prophylactically
  • B. Monitoring oxygen saturation with pulse oximetry
  • C. Encouraging deep breathing exercises
  • D. Administering bronchodilators as needed
Correct Answer: B

Rationale: Monitoring oxygen saturation with pulse oximetry is essential for preventing respiratory depression in a patient prescribed an opioid analgesic. Opioid analgesics can suppress the respiratory drive, leading to respiratory depression. By constantly monitoring the patient's oxygen saturation levels with pulse oximetry, nurses can promptly detect any signs of respiratory depression and intervene early to prevent serious complications. This allows for timely adjustments in the medication dosage or administration of other supportive measures to maintain adequate oxygenation and prevent respiratory compromise. Administering naloxone prophylactically may be necessary in case of an opioid overdose but is not typically done as a preventive measure. Encouraging deep breathing exercises can help prevent respiratory complications postoperatively but may not be sufficient in the presence of opioid-induced respiratory depression. Administering bronchodilators as needed is not directly related to preventing respiratory depression caused by opioid analgesics.

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You also emphasized that, "Communication must be culturally competent to be effective". Which of the following BEST reflects these statements?

  • A. Listen actively to what is said
  • B. Reflect on the meaning of the message
  • C. Use simple, direct words
  • D. Provide an appropriate environment
Correct Answer: A

Rationale: Actively listening to what is being said is a key component of effective communication that is culturally competent. By listening attentively and showing genuine interest in understanding the perspective of the speaker, you are better able to grasp the nuances of their communication style, values, and beliefs. This allows for more effective communication that takes into consideration the cultural context of the person you are communicating with. Developing active listening skills helps in building rapport, fostering understanding, and promoting mutual respect in cross-cultural interactions.

Disclosure of client information beyond the interdisciplinary team without consent of the client is a breach of ______.

  • A. confidentiality
  • B. duty
  • C. beneficence
  • D. veracity
Correct Answer: A

Rationale: Confidentiality is the ethical principle that requires healthcare providers to keep client information private and not disclose it without the client's consent. When client information is shared beyond the interdisciplinary team without the client's consent, it breaches the trust and privacy expected in the nurse-client relationship. This breach not only violates the ethical principle of confidentiality but also undermines the client's autonomy and right to control their own personal information. Maintaining confidentiality is crucial for building trust and ensuring the well-being of the client.

A postpartum client is breastfeeding and expresses discomfort during feedings due to sore nipples. What nursing intervention should be prioritized to alleviate nipple soreness?

  • A. Educating the client on proper latch technique
  • B. Recommending the use of nipple shields during feedings
  • C. Applying lanolin cream to the nipples after each feeding
  • D. Encouraging the use of breast pumps instead of direct breastfeeding
Correct Answer: A

Rationale: Proper latch technique is the most important nursing intervention to alleviate nipple soreness in a breastfeeding client. When a baby latches on correctly, it helps prevent nipple trauma and soreness. Educating the client on how to achieve a proper latch, such as ensuring the baby's mouth covers both the nipple and areola, can significantly reduce discomfort during feedings. Improving the latch can also enhance milk transfer, leading to better breastfeeding outcomes for both the mother and baby. While lanolin cream (choice C) can provide some relief for sore nipples, addressing the root cause by correcting the latch is crucial for long-term comfort and successful breastfeeding. Using nipple shields (choice B) or encouraging the use of breast pumps (choice D) should not be the first line of intervention when addressing sore nipples, as they do not address the underlying issue of latch technique.

A patient in the ICU develops acute kidney injury (AKI) secondary to hypovolemic shock. What intervention should the healthcare team prioritize to manage the patient's renal function?

  • A. Administer intravenous fluids to restore circulating volume.
  • B. Initiate continuous renal replacement therapy (CRRT) for RRT.
  • C. Implement strict dietary restrictions to reduce renal workload.
  • D. Recommend nephrotoxic medications for therapeutic purposes.
Correct Answer: A

Rationale: In a patient with acute kidney injury (AKI) secondary to hypovolemic shock, the priority intervention to manage the patient's renal function is to administer intravenous fluids to restore circulating volume. Hypovolemic shock leads to decreased blood flow to the kidneys, resulting in hypoperfusion and ischemic damage to the renal tubules. Prompt correction of hypovolemia with intravenous fluids helps improve renal perfusion and function by increasing blood flow to the kidneys. Adequate fluid resuscitation can potentially prevent further kidney damage and support kidney function recovery. It is crucial to address the underlying cause of AKI (hypovolemia in this case) to prevent complications and improve patient outcomes. Initiating renal replacement therapy or recommending nephrotoxic medications would not be the initial interventions for managing AKI in this scenario.

Which of the following is a common complication associated with benign prostatic hyperplasia (BPH)?

  • A. Urinary retention
  • B. Erectile dysfunction
  • C. Urethral stricture
  • D. Renal calculi
Correct Answer: A

Rationale: Benign prostatic hyperplasia (BPH) can lead to urinary retention, which is a common complication associated with this condition. As the prostate gland enlarges, it can obstruct the flow of urine from the bladder through the urethra. This obstruction can result in difficulty starting to urinate, weak urine flow, frequent urination, incomplete bladder emptying, and eventually urinary retention. If left untreated, urinary retention can lead to serious complications such as urinary tract infections, bladder damage, kidney damage, and even kidney stones. Therefore, urinary retention is an important complication to be aware of in patients with BPH.

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