Adult Health Med Surg Nursing Test Banks

Correct Answer: C

Rationale: The correct information that the incoming nurse should chart is that she received 800 cc of IV fluid. It is crucial for the charting to accurately reflect the actual situation to provide an accurate record for the patient's care. In this scenario, the discrepancy between the endorsed amount (400 cc) and the observed amount (800 cc) should be documented to ensure transparency and continuity of care. This deviation from the expected amount should be clearly recorded for proper monitoring and evaluation of the patient's condition.

Correct Answer: B

Rationale: When a patient arrives in the emergency room, the nurse's first priority is to assess the patient's airway, breathing, and circulation, following the ABCs of emergency care. In this scenario, positioning the patient with the head lower than the extremities ensures proper blood flow to vital organs, especially the brain. This position helps to maintain perfusion to the brain and prevent complications such as hypotension and shock. Once the patient's position is optimized, the nurse can proceed with further interventions such as starting an intravenous line, stopping bleeding, and requesting laboratory examinations as needed.

Correct Answer: A

Rationale: Wearing a mask is an essential infection control measure to prevent the spread of respiratory illnesses, including COVID-19. By wearing a mask, Nurse Emma can reduce the risk of inhaling or exhaling respiratory droplets that may contain infectious particles, thus helping to protect herself and the family members she is visiting. Masks are particularly crucial when interacting with individuals who are sick or when physical distancing may be challenging. While using gloves, face shields, and gowns are also important infection control measures in certain situations, wearing a mask is the most relevant and effective measure during a home visit to prevent respiratory transmission of infections.

Correct Answer: A

Rationale: Demonstrating tandem breastfeeding positions and techniques should be prioritized as the nursing intervention to address the client's concerns about breastfeeding both infants simultaneously. Tandem breastfeeding involves nursing twins at the same time and can help enhance milk production, promote bonding with both infants, and save time for the mother. By showing the client the proper positions and techniques for tandem breastfeeding, the nurse can empower the client with the knowledge and skills needed to successfully breastfeed both infants together. This intervention can ultimately support the client in feeling more confident and competent in managing the challenges of breastfeeding twins.

Correct Answer: B

Rationale: The symptoms described—tachycardia, weight loss, and tremors—are consistent with hyperthyroidism. Graves' disease is the most common cause of hyperthyroidism and is an autoimmune disorder in which the thyroid gland is overactive. This condition can lead to an increased production of thyroid hormones, resulting in symptoms such as rapid heartbeat (tachycardia), unintended weight loss, and tremors. In contrast, Hashimoto's thyroiditis is an autoimmune disorder that causes hypothyroidism, leading to symptoms like fatigue, weight gain, and cold intolerance. Diabetes mellitus is a metabolic disorder characterized by high blood sugar levels, which typically presents with symptoms such as increased thirst, frequent urination, and fatigue. Thyroid nodules are growths within the thyroid gland that can sometimes be associated with overactive (hyperthyroidism) or underactive (hypothyroidism) thyroid function, but they do not