Adult Health 2 Final Exam

Correct Answer: A

Rationale: Before an MRI scan with contrast, the nurse should assess if the client has any metal implants. Metal implants can interfere with the magnetic field of the MRI, which can pose a risk to the client's safety and compromise the quality of the scan. Assessing for allergies to iodine or shellfish (Choice B) is important for contrast agents but not specific to metal implants. Claustrophobia assessment (Choice C) is relevant for MRI scans due to the confined space but not specific to metal implants. Past procedures (Choice D) are important for comparison but not directly related to the risks associated with metal implants during an MRI scan with contrast.

Correct Answer: C

Rationale: The correct non-pharmacological intervention the nurse should suggest first for a client experiencing anxiety and sleep issues is practicing relaxation techniques before bed. Relaxation techniques like deep breathing, progressive muscle relaxation, or mindfulness meditation can help reduce anxiety levels and promote better sleep naturally. Starting an exercise program (Choice A) can be beneficial but may not provide immediate relief for anxiety and sleep problems. Keeping a sleep diary (Choice B) can help identify patterns but does not directly address anxiety. Using sleep-inducing medications (Choice D) should be considered only after non-pharmacological interventions have been tried.

Correct Answer: C

Rationale: In this situation, the nurse should encourage the wife to continue shaving her husband. The rationale behind this is that the wife is already performing the task, so abrupt interference may lead to potential harm or emotional distress. It is crucial for the nurse to carefully observe the situation and assess for any safety concerns. While teaching proper techniques (Choice B) is important, it can be addressed later in a non-critical manner to prevent skin irritation and injury. Advising to shave against the hair growth (Choice A) may cause skin irritation and cuts. Although demonstrating the correct procedure (Choice D) may be helpful, it is essential to consider the current dynamics and respect the wife's autonomy in caring for her husband.

Correct Answer: C

Rationale: The correct intervention for a client experiencing difficulty expectorating thick secretions due to pneumonia is to encourage increased fluid intake. Increasing fluid intake helps to thin secretions, making them easier to expectorate. Administering antibiotics (Choice A) is important in treating pneumonia but does not directly address the issue of thick secretions. Chest physiotherapy (Choice B) may help in some cases, but increasing fluid intake is a more straightforward and effective intervention. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

Correct Answer: A

Rationale: Encouraging early ambulation is crucial following a total hip replacement surgery as it helps prevent complications such as deep vein thrombosis (DVT) by promoting circulation. Early ambulation also aids in preventing pneumonia, muscle atrophy, and pressure ulcers. Applying ice to the surgical site may help with pain and swelling, but it is not as critical in preventing complications as early ambulation. While monitoring the surgical site for signs of infection is important, it is not as crucial in preventing postoperative complications compared to early ambulation. Administering pain medication as prescribed is essential for comfort and pain management but does not directly prevent postoperative complications like early ambulation does.