Basics of Adult Health Nursing
Prior to her scheduled surgery, a patient states that she is very nervous and really does not understand what the surgical procedure is or how it will be performed. The nurse should:
A. Have the patient sign the consent and place it on the chart
B. Call the health care provider to review the procedure with the patient
C. Explain the procedure to the patient and her family
D. Provide the patient with a pamphlet explaining the procedure
B. Call the health care provider to review the procedure with the patient
Which IV solution should the nurse be prepared to administer to a client with a serum sodium level of 120 mEq/L and a serum potassium level of 4.3 mEq/L?
Hypertonic fluids (3%, .45%)
“saline solutions are also available in osmolar concentrations greater than that of the ECF. These solutions must be administered cautiously and usually only when the serum osmolality has decreased to dangerously low levels”
A nurse has taken a client’s blood glucose level and obtained a reading of 53 and confirmed a second reading of 53. The client is appropriately responsive to questioning, but is drowsy and appears pale. What intervention should the nurse prioritize in response to this proven assessment finding?
15 g of fast acting concentrated carbohydrate (Dex4 or OJ/apple juice)
A nurse who provides care in a busy postsurgical unit recognizes pts. Are at particular risk of thromboembolism during their immediate postoperative recovery. Which of the following isn’t a nursing intervention for preventing DVT?
Surgical intervention
Based on anatomical differences of the right and left lung, where would a shelled peanut aspirated by an adult be most likely to lodge?
Right mainstem bronchus
The nurse is preparing an elderly patient for surgery and the patient is scheduled for a general anesthetic. What complicatioin should the nurse closely monitor the patient for?
A. Low body temperature
B. Peripheral edema
C. UTI
D. Increased ability to resist stress
A. Low body temperature
A client with an IV line in place states having pain at insertion site. Assessment of the site reveals a vein that is red, warm, and hard. Which actions would the nurse take? Select all that apply.
It is phlebitis so the nurse would: discontinue IV and restart it in a new area and apply a warm, moist compress.
A diabetes nurse is teaching an older client who has been recently diagnosed with t2d about the importance of foot care. To reduce this client’s risk of developing a diabetic foot ulcer what practice should the nurse teach?
Daily inspections of all surfaces on the feet
The nurse is providing education to the pt. regarding preventing DVTs prior to discharge after hip surgery. Which of the following statements reassures the nurse that the pt. has understood the teaching?
If I have to sit for long periods of time like on an airplane or for a road trip. I will try to get up and walk as often as I can to encourage circulation.
Which of the following is not a risk factor for epistaxis?
Recurrent headaches
T/F: A patient requires a patent airway and spontaneous respirations before being transferred from the PACU.
True
Interpret the following ABG: pH 7.48, CO2 32, HCO3 30.
Uncompensated metabolic alkalosis
A client has been taking oral corticosteroids for several weeks per their doctor’s order. When performing health education with this client, the nurse should emphasize the need to
Provide education to patient about not abruptly stopping the corticosteroid because it can result in acute adrenal insufficiency
A pt. has been admitted to the hospital w/ exacerbation of HF that has resulted in pulmonary and peripheral edema. The nurse has been carefully monitoring the trajectory of the pts s/s of HF. How can the nurse best monitor the pts fluid balance?
By performing daily weights at the same time each day
A patient with long term COPD has which of the following ABG results indicating respiratory acidosis?
pH 7.27, CO2 55, HCO3 24
You are a postoperative nurse admitting a patient from the PACU. What is the first assessment you would make on this patient?
A. Heart rate
B. Nail perfusion
C. Core temperature
D. Patency of the airway
D. Patency of the airway
What will happen to fluids in the ECF space and ICF space if you administer an isotonic fluid IV to a client?
Cells remain the same
“isotonic fluids have a total osmolality close to that of the ECF and do not cause cells to swell or shrink”
The nurse is obtaining a health history from a client with DM who has been taking insulin for 20 years. The client has recently been put on long-acting insulin as well as their usual pre-meal (rapid acting) insulin. Which of the following statements tells the nurse that further education is needed?
I will just mix my long-acting insulin with my rapid-acting insulin in the same syringe
“long acting insulin cannot be mixed with any other insulin”
Following several months of increasing dyspnea on exertion a 71 year old woman has been diagnosed with mitral regurgitation. The woman is relieved to receive a diagnosis which explains her symptoms but doesn’t completely understand the root of her problem. How can the nurse best explain the womans health problem?
When your heart beats some of the blood that should go to your body is backing up into your heart because the valve leaks
T/F: Pulmonary arterial hypertension is very rare, occurs in women aged 20-40 years old, and is usually fatal within 5 years of diagnosis.
True
Where does postoperative nursing begin?
In the PACU
Your client with hyperkalemia is ordered furosemide 80 mg orally daily. The pharmacy sends up 20 mg tablets. How many will you administer?
4 tabs
The DKA client is demonstrating Kussmaul respirations. You might expect the client’s blood gas to be
A blood gas that demonstrates metabolic acidosis (abnormally low pH and a low HCO3)
The public health nurse is participating in a health fair and she interviews a woman with a history of HTN who is currently smoking one pack of cigs per day and admits to eating fast food at least 4 times a week. She has had no manifestations of CAD but a recent low density lipoprotein level of 144 was found. Based on her assessment, the nurse would expect this pt. to have which treatment?
Diet therapy and smoking cessation
The nurse is caring for a client diagnosed with rhinitis. Which is an example of complementary/alternative (OTC) therapy?
Vitamin C/Zinc lozenges