Basics of Adult Health Nursing
A newly admitted patient is guarding, hesitant to move, and grimacing but rates her pain as 1 out of 10 on a 0-10 pain scale. The nurse should:
A. Document the patient’s rating of her pain
B. Reinforce teaching about the pain scale system
C. Reassess the patient’s pain in 30 minutes
D. Repeat the assessment
B. Reinforce teaching about the pain scale system
Which electrolyte imbalances include water restriction as a treatment modality?
Hyponatremia
“in a patient with normal or excess fluid volume hyponatremia is treated by restricting fluid to a total of 800 mL in 24 hours”
Your patient has had the following intake 2 ½ cups of coffee (240mL/cup), 345 mL of grape juice, ¾ qt of milk, 320 mL of diet coke, 1 ¼ L of D5W IV and 2 oz of cold grits. What will you record as the total intake in mL for this patient? Do not round.
3265 mL (600+345+750+320+1250) *grits isn’t included bc it isn’t liquid at room temperature
A 64 year old man has sought care because of recent lower leg pain that occurs when he walks and diminishes when he rests. The nurse recognizes that this pt is experiencing intermittent claudication. What should the nurse suspect from this finding?
The patient has arterial insufficiency to his lower extremities
While the nurse is caring for a client diagnosed with COPD, which outcome would require a revision in the plan of care?
The client demonstrate intolerance to activity
A patient’s cancer-related pain has necessitated several doses of Hydromorphone (Dilaudid) over the past 48 hours. The nurse should ensure that this patient is also receiving:
A. An antiemetic
B. An NSAID
C. A stool softener
D. A diuretic
C. A stool softener
Interpret the following ABG: pH 7.5, CO2 27, HCO3 19.
Uncompensated respiratory alkalosis
A 15 year old client is brought to the ER w/ symptoms of hyperglycemia. Following diagnostic testing, a new diagnosis of DM is made. What classification will be used to describe a 15 year old with diabetes who requires daily insulin injections due to decreased insulin production and fasting hyperglycemia?
T1D—beta cell destruction results in decreased insulin production, unchecked glucose production by liver and hyperglycemia
A 69 year old man has been experiencing progressive dyspnea and activity intolerance in recent months and is currently undergoing a diagnostic workup for HF. During echo, the clinician is trying to determine if the man has systolic or diastolic HF. Which of the following is NOT a characteristic of diastolic HF?
Weak contraction during systole
The nurse is caring for a client of African descent who is having increased respiratory difficulty. When assessing the client’s oxygen status, which assessment technique is used to evaluate client cyanosis? Select all that apply.
Noting a dullness in skin color
Assessing the lips and gums
A surgical patient is receiving postoperative analgesic through a PCA pump. The nurse should prioritize assessment of which of the following?
A. Agitation
B. Respiratory depression
C. Fluid overload
D. Changes in skin integrity
B. Respiratory depression
Interpret the following ABG: pH 7.26, CO2 55, HCO3 23.
Uncompensated respiratory acidosis
A nurse is participating in a diabetes screening program. Which clients are at risk for developing t2d? select all that apply.
look back at question 14 for risk factors of T2D
A nurse has asked the unit educator what happens when a patient w/ pericarditis has an increase in the amount of fluid in the pericardial sac. What should the educator tell the nurse?
It raises the pressure inside the pericardial sac, compressing the heart
T/F: The best way to prevent COVID 19 is by frequent handwashing, wearing masks, quarantine, and social distancing.
True
What are some nonpharmacologic interventions?
•Massage
•Ice and heat therapies
•Transcutaneous electrical nerve stimulation (TENS)
•Distraction
•Skeletal muscle relaxation
•Guided imagery
•Hypnosis
•Music therapy
•Alternative therapies
Why are IV meds especially dangerous compared to enteral or topical medications?
Rapid introduction in the bloodstream
“while all meds may produce reactions, IV meds are especially dangerous due to the rapid introduction and absorption within the blood stream.”
In planning care of a client who has hyperthyroidism, the nurse has identified the nursing diagnosis of altered nutrition: less than body requirements. What intervention is the best response to this diagnosis?
Several well-balanced meals of small size, up to six times a day
A retired RN sought care from her primary care provider stating, “the anterior/superior part of my foot aches constantly these days, and it has gotten so bad it keeps me up at night. Also, I cant seem to get that foot warm no matter what I do. The nurse should recognize this pt. may be experiencing the symptoms of
Arterial insufficiency
Which of the following is a normal age-related change of the respiratory system?
Vital capacity decreases
What is the difference between tolerance and addiction?
●Tolerance: the need for increasing doses of opioids to achieve the same therapeutic effect
○An expected and normal consequence of opioid therapy
●Addiction: A behavioral pattern of substance use characterized by a compulsion to take the substance
○Frequently feared by patients, but occurs very rarely
Which condition or clinical manifestation indicates that the client’s treatment for hyperkalemia is effective?
Cardiac problems are lessened
“the most important consequence of hyperkalemia is its effect on the myocardium”
A client has just been diagnosed with t2d. the healthcare provider has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent has been prescribed for this client?
Metformin
A nurse is admitting a 32 year old woman who is to undergo major surgery and will be on bed rest for at least 48 hours. While doing the admission assessment, the pt. tells the nurse that she takes oral contraceptive. The nurse should recognize this puts the pt at an increased risk of developing what health problem?
DVT
A client underwent an abdominal surgery and refuses to get out of the bed and only able to pull 250 mL via incentive spirometer. What is this client at risk for?
Atelectasis and pneumonia