Adult Health Nursing Quizlet Final

Correct Answer: B

Rationale: The nurse's priority action after noticing a sudden drop in blood pressure after administering anesthesia is to assess the patient's airway, breathing, and circulation (ABCs). This is crucial to determine the immediate cause of the sudden drop in blood pressure and to ensure the patient's safety and stability. Assessment of the ABCs will help identify any potential airway obstruction, respiratory distress, or circulatory issues that may be contributing to the drop in blood pressure. Once the assessment is done, appropriate interventions can be initiated to stabilize the patient's condition. Administering vasopressors, documenting the blood pressure readings, and notifying the anesthesiologist are important actions but assessing the ABCs takes precedence in this situation to ensure the patient's immediate needs are addressed.

Correct Answer: C

Rationale: The patient's presentation of excessive thirst, frequent urination, and fatigue align with the classic symptoms of diabetes mellitus. The laboratory findings of hypernatremia (high sodium levels), hyperglycemia (high blood sugar levels), and metabolic acidosis further support this diagnosis. In diabetes mellitus, the body is unable to properly regulate blood sugar levels due to either insufficient insulin production (Type 1 diabetes) or ineffective use of insulin by the cells (Type 2 diabetes). This leads to high blood sugar levels, causing symptoms such as polyuria (frequent urination), polydipsia (excessive thirst), and fatigue. The metabolic acidosis is a result of the body's breakdown of fats and proteins for energy due to the lack of glucose utilization in the cells.

Correct Answer: B

Rationale: In the situation of an obstetric emergency requiring immediate delivery, the priority nursing action is to prepare the delivery room for the birth. This involves ensuring that all necessary supplies and equipment are readily available, the bed is adjusted to the appropriate position, and the healthcare team is prepared to assist with the birth. By expeditiously preparing the delivery room, the healthcare team can facilitate a safe and timely delivery for both the mother and the baby. Notifications to the healthcare provider, administering intravenous fluids, and continuous fetal monitoring can be done simultaneously but preparing the delivery room takes precedence to ensure a prompt response to the emergent situation.

Correct Answer: B

Rationale: It is important for the nurse to have a direct and easily accessible means of communication with the patient who is expected to be in and out of the hospital due to their chronic illness like leukemia. By asking for the patient's phone number, the nurse can quickly reach out to them for updates, clarification, or any urgent matters that may arise. This direct communication line helps in ensuring continuity of care and addressing the patient's needs promptly. This approach is more practical and efficient compared to options such as asking the patient to call the hospital number listed in the yellow pages or relying on chart information which may not always be up to date. Writing down the number and giving it to the ward clerk may cause unnecessary delays in communication.

Correct Answer: D

Rationale: Before any procedure, it is crucial to ensure that you have the proper authorization and guidelines in place. By checking the physician's order and the patient care plan, you confirm that suctioning is indeed needed and that you follow the specific instructions for that patient. This step helps ensure patient safety and effective care delivery. Once you have verified this information, you can proceed with gathering equipment, performing hand hygiene, and assessing the patient's condition as necessary.