Adult Health Nursing Answer Key

Adult Health Nursing Answer Key Related

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Which of the following actions is recommended for controlling severe external bleeding from an extremity?

  • A. Applying a tourniquet proximal to the injury site.
  • B. Elevating the extremity above the level of the heart.
  • C. Applying direct pressure with a sterile dressing.
  • D. Removing any impaled objects.
Correct Answer: C

Rationale: When controlling severe external bleeding from an extremity, the recommended action is to apply direct pressure with a sterile dressing. Direct pressure helps to stop the bleeding by promoting clot formation and reducing blood flow from the wound. This method is effective in most cases and should be the first response to control bleeding. Elevating the extremity above the level of the heart can be helpful in some cases, but direct pressure is the initial recommended action. Applying a tourniquet proximal to the injury site should only be done as a last resort when other methods are not successful, as it can lead to complications such as tissue damage. Removing any impaled objects can actually worsen the bleeding and should be avoided unless necessary for immediate life-saving measures.

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When the nurse interacts with patients face-to-face such as in getting information during the assessment phase of the nursing process, the level of communication is which of the following?

  • A. Intrapersonal
  • B. Public communication
  • C. Interpersonal
  • D. Verbal
Correct Answer: C

Rationale: When the nurse interacts with patients face-to-face to gather information during the assessment phase of the nursing process, the level of communication is considered interpersonal. Interpersonal communication involves two or more individuals who are connected in a meaningful way. In this scenario, the nurse and the patient are engaging in a personal exchange of information, thoughts, and feelings. This type of communication is essential in building rapport, understanding the patient's needs, and providing effective care. It focuses on creating a supportive and therapeutic relationship between the nurse and the patient, which is crucial for delivering high-quality nursing care.

times. II before removing from the shelf. III before measuring actual dose. IV before opening a unit dose-container.

  • A. II & III
  • B. I, II & III
  • C. I & II
  • D. I, II, III, & IV
Correct Answer: D

Rationale: It is important to check the medication label against the medication order before administering any medication to ensure accuracy.

Who among the passengers will take PRIORITY for the rescue team to transport to the hospital?

  • A. Student with Colle's fracture.
  • B. Jay with lacerations
  • C. Pregnant women
  • D. Conductor with broken leg
Correct Answer: C

Rationale: In emergency situations, pregnant women are typically given priority when it comes to transportation to the hospital. This is because they have unique medical needs and potential complications that require immediate attention. It is important to ensure the well-being of both the mother and the unborn child. Additionally, the health and safety of the unborn child are critical considerations in determining priority for medical treatment and transport. Therefore, the pregnant woman should be the priority for the rescue team to transport to the hospital.

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.

The female client who is very anxious and fidgety is blowing off to much carbon dioxide develops tingling sensation of the lips and fingers and is not able to control her respirations. The MOST appropriate nursing intervention for this client is to _____.

  • A. Instruct the client to blow her nose and take deep breath
  • B. Administer oxygen
  • C. Have the client breath into a paper bag
  • D. Administer IV fluids as ordered
Correct Answer: C

Rationale: The client is experiencing symptoms of hyperventilation, a condition that occurs when there is excessive elimination of carbon dioxide from the body. Breathing into a paper bag can help by allowing the client to rebreathe carbon dioxide, which can help restore the balance of gases in the blood and alleviate the tingling sensations in the lips and fingers. This technique is commonly used to help regulate breathing in cases of hyperventilation. Administering oxygen (choice B) may not be necessary as the issue lies with an imbalance of carbon dioxide, not a lack of oxygen. Instructing the client to blow her nose and take deep breaths (choice A) may not address the underlying problem effectively. Administering IV fluids (choice D) is not relevant to the client's symptoms of hyperventilation.

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