Adult Health Nursing Answer Key

Correct Answer: C

Rationale: Opioid analgesics are known to suppress the respiratory centers in the brain, leading to respiratory depression as a side effect. This adverse effect is particularly dangerous and potentially life-threatening, especially in patients who are opioid-naive or when high doses are administered. Therefore, it is crucial for the nurse to closely monitor the patient's respiratory rate, depth, and effort while on opioid analgesic therapy to detect early signs of respiratory depression and intervene promptly to prevent complications. Hypertension, hypoglycemia, and hyperkalemia are not commonly associated with opioid analgesics.

Correct Answer: B

Rationale: In the grading system used for edema, +1 indicates no visible edema in the leg, +2 indicates slight edema with indentations that quickly resolve, +3 indicates moderate edema with deeper indentations that may take longer to resolve, and +4 indicates severe edema with very swollen legs. In this case, since the edema is described as slightly swollen, the appropriate grade to document would be +2.

Correct Answer: C

Rationale: Insulin glargine (Lantus) is a long-acting insulin that is typically administered once daily at the same time each day to help maintain a steady level of insulin in the body. It is important to rotate injection sites within the same body region (such as the abdomen, thigh, or upper arm) to prevent lipodystrophy (lumpiness or dents in the skin) and to ensure consistent absorption of the insulin. Proper rotation of injection sites helps to prevent tissue damage and ensures optimal insulin absorption, improving the effectiveness of insulin therapy. It is not necessary to inject insulin glargine before meals, vigorously shake the vial, or administer it with a rapid-acting insulin.

Correct Answer: D

Rationale: #NAME?

Correct Answer: B

Rationale: The order for isotonic intravenous (IV) infusion indicates that the IV solution should have an osmolarity similar to that of blood serum, which is approximately 0.9 percent sodium chloride solution (normal saline). In the given choices, the closest option to isotonic solution is the 0.45 percent sodium chloride solution. This solution is hypotonic compared to blood serum, making it a suitable choice for isotonic IV infusion to prevent fluid shifts and maintain electrolyte balance in the patient. The other options, such as 5 percent dextrose in water (hypotonic), 10 percent dextrose in water (hypertonic), and 3 percent sodium chloride solution (hypertonic), do not match the requirement for an isotonic IV solution in this case.