Adult Health Exam 1

Adult Health Exam 1 Related

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The nurse is providing preoperative teaching to a client who will undergo a thyroidectomy. What information should the nurse include about postoperative care?

  • A. Importance of maintaining neck stability
  • B. How to care for the surgical drain
  • C. Pain management strategies
  • D. All of the above
Correct Answer: D

Rationale: Providing preoperative teaching for a client undergoing a thyroidectomy is essential to prepare them for postoperative care. Information about the importance of maintaining neck stability is crucial to prevent complications such as strain on the surgical site. Teaching the client how to care for the surgical drain is important to prevent infections, ensure proper wound healing, and aid in monitoring postoperative recovery. Pain management strategies are vital to ensure the client's comfort and promote optimal recovery. Including all these aspects in preoperative teaching ensures the client is well-prepared for comprehensive postoperative care. Therefore, the correct answer is D because all these elements are essential components of postoperative care for a client undergoing a thyroidectomy. Choices A, B, and C are all important aspects of postoperative care that the nurse should include in the preoperative teaching session.

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The nurse is assessing a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

  • A. Slow the rate of transfusion.
  • B. Administer an antipyretic.
  • C. Stop the transfusion immediately.
  • D. Notify the healthcare provider.
Correct Answer: C

Rationale: The correct answer is C: Stop the transfusion immediately. Chills and back pain are indicative of a possible transfusion reaction, which is a critical situation. Stopping the transfusion is crucial to prevent further complications and ensure the client's safety. Slowing the rate of transfusion (Choice A) is not sufficient in this case as immediate action is required. Administering an antipyretic (Choice B) may help with fever but does not address the potential severe reaction. Notifying the healthcare provider (Choice D) can be done after stopping the transfusion, but the priority is to halt the infusion to prevent harm.

During a routine prenatal visit, a nurse measures a client's fundal height. The client is 26 weeks pregnant. What should the fundal height be?

  • A. Approximately 26 cm
  • B. Between 24 to 28 cm
  • C. Above the umbilicus by two finger widths
  • D. Below the xiphoid process
Correct Answer: B

Rationale: The correct answer is B: Between 24 to 28 cm. Fundal height corresponds to the weeks of gestation, so at 26 weeks of pregnancy, the fundal height should range between 24 to 28 cm. This measurement is a quick way to assess fetal growth and amniotic fluid volume. Choice A is incorrect because fundal height may vary and not always match the exact weeks of pregnancy. Choice C, measuring above the umbilicus by two finger widths, is not a standard method for fundal height measurement. Choice D, below the xiphoid process, is too high and not relevant for assessing fundal height during pregnancy.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing shortness of breath. What is the priority nursing intervention?

  • A. Administer bronchodilator therapy as prescribed.
  • B. Inhale the medication slowly while pressing down on the inhaler.
  • C. Position the client in a high-Fowler's position.
  • D. Increase the oxygen flow rate.
Correct Answer: C

Rationale: The priority nursing intervention for a client with COPD experiencing shortness of breath is to position the client in a high-Fowler's position. This position helps improve lung expansion and ease breathing by maximizing chest expansion and allowing for better airflow. While administering bronchodilator therapy is important, positioning the client for improved breathing takes priority. Inhaling the medication slowly and pressing down on the inhaler is a correct technique for inhaler use but not the priority intervention. Increasing the oxygen flow rate may be needed, but adjusting the client's position to a high-Fowler's position is the priority to address the shortness of breath in COPD.

A client with a severe headache is being assessed by a nurse. What should the nurse do first?

  • A. Administer pain relief medication
  • B. Check the client's blood pressure
  • C. Assess for associated symptoms such as nausea or photophobia
  • D. Offer a quiet environment
Correct Answer: B

Rationale: When a client presents with a severe headache, the initial action should be to check their blood pressure. This step is crucial as it can help determine if the headache is related to hypertension or other cardiovascular issues. Administering pain relief medication should only be done after assessing the client's vital signs and confirming the cause of the headache. While assessing for associated symptoms like nausea or photophobia is important for a comprehensive evaluation, it should follow checking the blood pressure to address immediate concerns. Offering a quiet environment is indeed beneficial for the client's comfort, but it is not the priority when dealing with a severe headache.

A client is admitted with a diagnosis of myocardial infarction (MI). Which intervention is a priority during the acute phase?

  • A. Administer morphine for pain relief
  • B. Encourage the client to perform isometric exercises
  • C. Position the client flat in bed
  • D. Restrict fluid intake
Correct Answer: A

Rationale: During the acute phase of a myocardial infarction (MI), the priority intervention is to administer morphine for pain relief. Morphine not only alleviates pain but also reduces myocardial oxygen demand, which is crucial in the management of MI. Encouraging the client to perform isometric exercises (choice B) can increase myocardial oxygen demand and should be avoided during the acute phase. Positioning the client flat in bed (choice C) may worsen symptoms by increasing venous return and workload on the heart. Restricting fluid intake (choice D) is not a priority intervention during the acute phase of MI; maintaining adequate hydration is important for organ perfusion.

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