Adult Health Nursing Quizlet Final

Correct Answer: A

Rationale: In this case, the patient is experiencing respiratory acidosis as indicated by the low pH (7.28), elevated PaCO2 (65 mmHg), and elevated HCO3- (30 mEq/L). The primary acid-base disturbance is respiratory acidosis due to the retention of carbon dioxide (PaCO2 >45 mmHg) leading to an increase in HCO3- as a compensatory mechanism to maintain pH within normal limits. The elevated HCO3- levels (metabolic compensation) are trying to counterbalance the increased PaCO2 levels (respiratory acidosis) by increasing bicarbonate to attempt to normalize the pH. Overall, the ABG analysis shows respiratory acidosis with metabolic compensation in this COPD patient with an acute exacerbation and severe dyspnea.

Correct Answer: B

Rationale: Radiologic procedures are typically not used as the least screening assessment by nurses in a perinatal unit. The nurse's initial screening assessments usually focus on gathering information through techniques such as physical examination, interviews, and reviewing laboratory results. Radiologic procedures, such as X-rays or CT scans, are usually ordered by physicians once a more specific diagnostic need has been identified, based on the initial screening assessments performed by the nurse. Therefore, in this scenario, the least screening assessment to be used by the nurse would be radiologic procedures.

Correct Answer: A

Rationale: The most appropriate intervention for managing hepatic encephalopathy in this patient receiving palliative care for end-stage liver disease is to administer lactulose or other ammonia-lowering agents to reduce ammonia levels. Hepatic encephalopathy is believed to be primarily caused by the accumulation of ammonia in the bloodstream due to compromised liver function. Lactulose works by acidifying the gut lumen, which facilitates the excretion of ammonia in the form of ammonium ions. By reducing ammonia levels, hepatic encephalopathy symptoms, such as confusion and altered mental status, can be improved. Initiating other supportive measures like managing precipitating factors, maintaining hydration, and addressing nutritional issues should also be part of the holistic approach in managing hepatic encephalopathy in palliative care. However, addressing the underlying cause by reducing ammonia levels with lactulose is the priority intervention in this scenario.

Correct Answer: D

Rationale: Incident reports (IR) are filed in the Records Section of the hospital. It is important for incident reports to be kept in the Records Section for various reasons. By being filed in the hospital's official records, incident reports are included in the hospital's documentation of events, which is crucial for legal and quality improvement purposes. Placing IRs in the Records Section ensures that they are accessible to relevant personnel who may need to refer to them in the future for investigations, audits, or further actions related to the incidents. Keeping incident reports in a centralized location like the Records Section also helps in standardizing the process of documenting and tracking incidents, maintaining consistency and accountability within the healthcare facility.

Correct Answer: A

Rationale: Rhinitis is inflammation of the nasal mucosa, and common clinical manifestations include nasal congestion (blockage or stuffiness), rhinorrhea (runny nose), and sneezing. These symptoms are often present in both allergic and non-allergic rhinitis. While headaches, sore throat, and fever can occur in some cases, they are not as specific to rhinitis as nasal congestion, rhinorrhea, and sneezing.