Foundations and Adult Health Nursing Study Guide Answers

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Which of the following actions is indicated in the management of a patient with an open chest wound (sucking chest wound)?

  • A. Applying a sterile dressing and occlusive dressing.
  • B. Administering supplemental oxygen.
  • C. Providing reassurance and emotional support.
  • D. Elevating the patient's legs to improve venous return.
Correct Answer: A

Rationale: An open chest wound, also known as a sucking chest wound, can lead to a collapsed lung and respiratory distress. Immediate management involves sealing the wound to prevent air from entering the pleural space and further compromising the patient's respiratory function. Applying a sterile dressing over the wound helps to prevent contamination and occluding the wound with an airtight covering, such as an occlusive dressing, can effectively reduce the risk of a tension pneumothorax, a serious complication that can arise from a sucking chest wound. These interventions help to stabilize the patient's condition and improve the chances of a successful recovery. Administering supplemental oxygen, though beneficial, would be secondary to the primary management of sealing the chest wound. Providing emotional support is important but addressing the physical emergency takes precedence. Elevating the patient's legs would not be appropriate in managing an open chest wound.

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When a patient is admitted to the OB ward with complains of dizziness and body weakness, this is an example of______.

  • A. secondary source
  • B. objective data
  • C. primary source
  • D. Subjective data
Correct Answer: D

Rationale: When a patient is admitted to the OB ward with complaints of dizziness and body weakness, this information pertains to what the patient is feeling or experiencing, which is subjective data. Subjective data is based on the patient's symptoms, feelings, and experiences as reported by the patient themselves. In this case, dizziness and body weakness are subjective symptoms described by the patient, and they cannot be objectively measured or quantified. It is essential for healthcare providers to consider subjective data along with objective data (measurable and observable signs) when assessing and diagnosing a patient's condition.

A patient is prescribed a beta-adrenergic agonist for the management of asthma. Which adverse effect should the nurse monitor closely in the patient?

  • A. Hypotension
  • B. Hyperkalemia
  • C. Tachycardia
  • D. Hypoglycemia
Correct Answer: C

Rationale: Beta-adrenergic agonists stimulate beta-adrenergic receptors in the heart, leading to an increase in heart rate (tachycardia). This is a common adverse effect associated with the use of beta-adrenergic agonists in the management of conditions such as asthma. Monitoring for tachycardia is important because it can potentially lead to other complications such as palpitations, arrhythmias, and exacerbation of underlying cardiovascular conditions. It is essential for the nurse to closely monitor the patient for any signs or symptoms of tachycardia and report any abnormalities to the healthcare provider promptly to ensure appropriate management and prevent further complications.

Nurse Vince is going to refer patient to secondary health facility. Which of the following is an example of secondary health facility?

  • A. District hospital
  • B. Rural health unit
  • C. Puereculture Center
  • D. Barangay health station
Correct Answer: A

Rationale: A district hospital is an example of a secondary health facility. Secondary health facilities are the intermediate level of healthcare services, providing a higher level of care compared to primary health facilities like rural health units and barangay health stations. District hospitals typically offer more specialized medical services, diagnostic facilities, and inpatient care that are not available at lower-level health facilities. When Nurse Vince refers a patient to a district hospital, it means that the patient requires more extensive and specialized medical care beyond what can be provided at the primary level of care.

Which of the following diagnostic tests is most appropriate for evaluating a woman with suspected cervical dysplasia?

  • A. Pap smear
  • B. Endometrial biopsy
  • C. Colposcopy with biopsy
  • D. Transvaginal ultrasound
Correct Answer: C

Rationale: Colposcopy with biopsy is the most appropriate diagnostic test for evaluating a woman with suspected cervical dysplasia. Colposcopy is a procedure in which a special magnifying instrument called a colposcope is used to examine the cervix for any abnormal areas. If abnormal tissue is identified during colposcopy, a biopsy will be taken to confirm the presence of cervical dysplasia and determine the severity. This allows for a more accurate diagnosis and appropriate management of the condition. Pap smear, although a screening test for cervical dysplasia, may not provide a definitive diagnosis and may require further evaluation with colposcopy and biopsy. Endometrial biopsy and transvaginal ultrasound are not indicated for evaluating cervical dysplasia specifically.

What IMMEDIATE danger should the nurse anticipate post Transurethral Resection of the Prostate (TURP)?

  • A. Infection
  • B. Thrombosis
  • C. Bleeding
  • D. Shock
Correct Answer: C

Rationale: Post Transurethral Resection of the Prostate (TURP), the immediate danger that the nurse should anticipate is bleeding. TURP is a surgical procedure that involves removing portions of the prostate gland through the urethra. Due to the nature of the surgery and the rich blood supply to the prostate, bleeding is a common complication post-TURP. Excessive bleeding can lead to hypovolemic shock, which is a life-threatening condition. Therefore, monitoring for signs of bleeding, such as blood in the urine, drop in hematocrit levels, hypotension, tachycardia, and signs of hypovolemic shock, is crucial to prevent any serious complications. Proper assessment, monitoring, and timely intervention are essential in managing post-TURP bleeding and preventing adverse outcomes.

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