Adult Health Nursing Study Guide Answers

Correct Answer: A

Rationale: Acute pyelonephritis is the most likely condition based on the patient presentation and urinalysis findings described. Acute pyelonephritis is an infection of the renal parenchyma and pelvis, typically caused by ascending bacteria from the lower urinary tract. The classic symptoms include fever, chills, flank pain, and costovertebral angle tenderness (tenderness over the kidneys). The presence of pyuria (pus in the urine) and bacteriuria (bacteria in the urine) on urinalysis further supports the diagnosis of acute pyelonephritis. It is crucial to diagnose and treat acute pyelonephritis promptly to prevent complications and recurrent infections.

Correct Answer: C

Rationale: The nurse should prioritize checking the patency of the NG tube by aspirating gastric contents before initiating tube feeding. This is important to ensure that the NG tube is in the correct position and that it is functioning properly. By aspirating gastric contents, the nurse can confirm that the tube is in the stomach and not in the lungs or surrounding tissues. If no gastric contents are obtained upon aspiration, it may indicate that the tube is not properly placed or may be occluded, which would require further assessment and intervention before proceeding with tube feeding. Checking the patency of the NG tube is a crucial step in ensuring the safety and effectiveness of enteral nutrition delivery.

Correct Answer: A

Rationale: Acute pyelonephritis is the most likely condition based on the patient presentation and urinalysis findings described. Acute pyelonephritis is an infection of the renal parenchyma and pelvis, typically caused by ascending bacteria from the lower urinary tract. The classic symptoms include fever, chills, flank pain, and costovertebral angle tenderness (tenderness over the kidneys). The presence of pyuria (pus in the urine) and bacteriuria (bacteria in the urine) on urinalysis further supports the diagnosis of acute pyelonephritis. It is crucial to diagnose and treat acute pyelonephritis promptly to prevent complications and recurrent infections.

Correct Answer: A

Rationale: The sensation of feeling "heavy" in the perineal area postpartum is a common concern due to the stretching and potential trauma to the perineal muscles during childbirth. Kegel exercises are specifically designed to strengthen the pelvic floor muscles, which can help alleviate this sensation of heaviness. By encouraging the client to perform Kegel exercises regularly, the nurse is promoting the restoration and strengthening of the perineal muscles, ultimately helping the client feel more comfortable and supported in that area. This education empowers the client to take an active role in their own recovery and promotes optimal healing postpartum.

Correct Answer: C

Rationale: In the provided scenario, the patient is scheduled for Lithotripsy under spinal anesthesia. This means that the nurse needs to communicate with the department of anesthesia to coordinate and prepare for the procedure. Anesthesia departments are responsible for administering various types of anesthesia, including spinal anesthesia, to ensure patients are comfortable and pain-free during medical procedures. Therefore, contacting the department of anesthesia is crucial in this situation to ensure that the necessary arrangements are in place for the patient's lithotripsy procedure.