Adult Health Nursing Test Bank

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During the active phase of labor, a woman's cervical dilation is progressing slowly despite regular contractions. What maternal condition should the nurse assess for that may contribute to abnormal labor progression?

  • A. Maternal exhaustion
  • B. Pelvic outlet obstruction
  • C. Fetal macrosomia
  • D. Uterine hyperstimulation
Correct Answer: B

Rationale: One potential maternal condition that may contribute to abnormal labor progression with slow cervical dilation despite regular contractions is pelvic outlet obstruction. This can occur if the maternal pelvis is too small, misshapen, or has an obstruction such as a fibroid tumor. The inadequate space in the pelvis can prevent the fetus from descending properly and can result in a prolonged or difficult labor. If suspected, interventions such as a cesarean delivery may be necessary to prevent complications for both the mother and baby. It is essential for the nurse to assess for signs of pelvic outlet obstruction and work with the healthcare team to address any issues promptly to ensure a safe delivery.

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A patient presents with severe sore throat, fever, and enlarged tonsils with exudate. Rapid antigen testing confirms group A beta-hemolytic Streptococcus (GAS) infection. Which of the following medications is the first-line treatment for this condition?

  • A. Amoxicillin
  • B. Azithromycin
  • C. Cephalexin
  • D. Clindamycin
Correct Answer: A

Rationale: The correct answer is A: Amoxicillin. Amoxicillin is the first-line treatment for GAS pharyngitis due to its effectiveness against Streptococcus bacteria. It is a penicillin-class antibiotic recommended by guidelines. Azithromycin is an alternative for patients allergic to penicillin. Cephalexin is not the first-line choice for GAS. Clindamycin is reserved for patients allergic to both penicillin and macrolides.

To promote drainage and reduce pressure from fluid, Nurse Selma nursing intervention is to have the child assume any of the following positions, EXCEPT _____.

  • A. tilt head to side if sitting up.
  • B. Lie on the affected area
  • C. put the pillows behind the head
  • D. lie on the non-affected ear.
Correct Answer: B

Rationale: The correct answer is B: Lie on the affected area. This position would hinder drainage and increase pressure on the affected area. A: Tilt head to the side if sitting up, is correct as it promotes drainage. C: Putting pillows behind the head can also aid drainage. D: Lying on the non-affected ear can help reduce pressure on the affected side.

During surgery, the nurse notices that the patient's blood pressure is trending higher than the baseline. What action should the nurse take?

  • A. Administer antihypertensive medication
  • B. Document the blood pressure readings in the anesthesia record
  • C. Notify the anesthesia provider for further assessment
  • D. Continue monitoring the patient's blood pressure closely
Correct Answer: C

Rationale: The correct answer is C: Notify the anesthesia provider for further assessment. This is the most appropriate action because an anesthesia provider is trained to assess and manage changes in blood pressure during surgery. Administering antihypertensive medication (A) without proper assessment can be dangerous. Documenting the readings (B) is important but not the immediate action. Continuing to monitor closely (D) is necessary but notifying the anesthesia provider for further assessment should be the priority.

Which of the following structures is responsible for the production of digestive enzymes and bicarbonate-rich pancreatic juice?

  • A. Liver
  • B. Gallbladder
  • C. Pancreas
  • D. Spleen
Correct Answer: C

Rationale: The correct answer is C: Pancreas. The pancreas is responsible for producing digestive enzymes and bicarbonate-rich pancreatic juice. It secretes enzymes like amylase, lipase, and protease to break down carbohydrates, fats, and proteins in the small intestine. The bicarbonate-rich juice helps neutralize stomach acid. The liver (A) produces bile stored in the gallbladder (B), which aids in fat digestion. The spleen (D) is involved in immune function and blood filtration, not digestive enzyme production.

Nurse Rica, would like to start a conversation, which comunication technique she should use?

  • A. Clarifying
  • B. Challenging
  • C. Restating
  • D. Broad opening
Correct Answer: D

Rationale: The correct answer is D, Broad opening. Nurse Rica should use this communication technique to encourage the patient to freely express themselves without leading or interrupting. This technique helps build rapport and trust, setting a positive tone for the conversation.

A: Clarifying may be too direct and might make the patient feel pressured.
B: Challenging can create defensiveness and hinder open communication.
C: Restating may not be as effective in initiating a conversation as broad opening.

In summary, broad opening allows for a more open and relaxed conversation, fostering a conducive environment for effective communication with the patient.

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