Basics of Adult Health Nursing
T/F: The scope of practice specifies particular interventions that are appropriate for patients who have specific medical and nursing diagnoses
What is False?
Which nursing intervention is the most reliable indicator of fluid loss or fluid gain?
What is daily weights ?
“Daily body weights are monitored; an acute loss of 1 lb represents a fluid loss of approximately 500mL”—body weight changes can account for insensible water loss, whereas I&O cannot.
A client has been admitted to an acute medical unit with a diagnosis of diabetes insipidus with a neurogenic etiology. When planning the client’s care, what diagnosis should be the nurse’s most likely priority?
What is maintaining adequate fluid volume, monitoring patient’s weight, administering vasopressin, monitoring VS, and monitoring patient’s intake and output?
The nurse is caring for a client with a new prescription of digoxin. Which client statement would require further teaching about digoxin? Select all that apply.
what is I will take antacid with my digoxin?
You go to help assess a patient in respiratory distress. The patient has dyspnea, appears hungry, and is coughing up pink frothy sputum. What is the most likely diagnosis?
what is Pulmonary edema?
The nurse is helping a patient and her family in planning the patient’s return to work after a surgery. Which level of Maslow’s Hierarchy of Needs does the patient need for self-fulfillment fit on?
What is Self-actualization?
Interpret the following ABG:
pH- 7.32
CO2- 33
HCO3- 18
What is uncompensated metabolic acidosis?
Which lab should be checked prior to the administration of metformin?
What is creatinine?
“metformin is contraindicated in patients with kidney impairment and in those at risk for acute kidney dysfunction”
The nurse is caring for a client with HF. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse contacts the HCP and prepares to implement which priority intervention?
what is administer o2 and administer furosemide?
You have a patient on a 10 L/min simple mask with an o2 sat of 85%. Which oxygen delivery system will you place on the patient to deliver the highest oxygen saturation?
what is Non-rebreather mask?
The Occupational Health and Safety Administration is responsible for:
What is Ensuring safe working environments?
A nurse is caring for an older client following surgery. The client has a fluid volume deficit and a serum sodium level of 130 mEq/L. The nurse should monitor this client for symptoms of:
What is Hypovolemia and hyponatremia?
“sodium is the most abundant electrolyte in the ECF; its concentration ranges from 135-145”
Which hormone is produced by the alpha cells of the pancreas that stimulates the liver to convert glycogen to glucose?
What is glucagon?
The nurse is awaiting the arrival of a client from the ER with a diagnosis of anterior wall myocardial infarction. In caring for this client, the nurse would be alert for which s/s of left-sided heart failure? Select all that apply.
what is
Dyspnea
Crackles
Fatigue
A client with acute asthma is being treated for inspiratory and expiratory wheezes and a decreased forced expiratory volume. Which class of prescribed drug should the nurse administer to this client?
what is Bronchodilators?
What is the difference between health and wellness?
What is
Health:“The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”
Wellness:
“Implies a proactive process toward a goal of physical, psychological, and spiritual well-being in which people of any age and in various stages of health are willing to ‘work hard’.” (Kiefer, 2008). Increasing emphasis is placed on health, health promotion, wellness, and self-care
A patient in the hospital has a severely elevated magnesium level. What intervention would you perform first in relation to this patient?
What is stop all magnesium medications?
“In patients with severe hypermagnesemia, all parenteral and oral magnesium salts are discontinued”
A 78 year old client with T2D is brought the ED. He is found to have a BG level of 623. His daughter reports he recently had a GI virus and has been confused for the 3 hours. A diagnosis of hyperglycemic hyperosmolar nonketotic syndrome is made. What nursing action would be the priority?
What is replace fluids, correct electrolyte imbalances, and administer insulin?
A community health nurse is providing an educational event at the local seniors center. The topic the nurse is speaking about is varicose veins. What would the nurse suggest as proactive preventative measures for varicose veins?
what is Walking for several minutes every hour to promote circulation?
A nurse assigned to a client with emphysema, is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply.
what is
Teach diaphragmatic/pursed lip breathing
Administer low-flow o2 as needed
Encourage alternating client activity with rest periods
Teach the use of postural drainage and chest physiotherapy
What are the levels of Maslow's Hierarchy of Needs from top to bottom?
What is self-actualization, esteem, love and belonging, safety needs, physiological needs?
A patient is having her blood pressure checked by the PCT. The PCT comes to you to infrom you that when she pump up the cuff the patients thumb curved in toward the palm, her wrest flexed downward, and her fingers splayed out. As soon as the cuff deflated it stopped. The nurse knows this is called.
What is Trousseau sign?
“trousseau sign can occur with hypocalcemia or hypomagnesemia. Occluding the brachial artery with a blood pressure cuff for 3 minutes can produce this”
Which two insulins can be mixed and administered together?
What is Regular and NPH?
T/F: Tissue valves deteriorate more quickly and have a higher incidence of infection than mechanical valves.
What is true?
A client with a history of asthma presents in the physicians office with complaints of difficulty breathing. While performing the initial assessment, the nurse becomes concerned that the client’s respiratory status has worsened based on which of the following?
what is Audible wheezing?