Adult Health Nursing Test Bank

Correct Answer: D

Rationale: The correct answer is D: Tilt the head slightly forward and angle the bottle toward the side of the nostril. This method allows for proper administration of the spray into the nasal passage, ensuring effective delivery of the medication. Tilted head helps direct the spray towards the nasal cavity without causing discomfort or leakage. It also helps prevent the medication from dripping down the back of the throat. Choices A, B, and C are incorrect: A: Finishing instillation in one nostril before moving to the other can lead to uneven distribution of medication and reduced effectiveness. B: Inhaling quickly may cause irritation and discomfort to the mucous membranes due to the forceful intake of the spray. C: Blowing the nose after spraying can expel the medication before it has a chance to be absorbed, decreasing its efficacy.

Correct Answer: A

Rationale: The correct immediate action is to inform the surgeon and anesthesiologist (Choice A) because a sudden decrease in oxygen saturation during surgery is a critical situation that requires prompt attention from the entire surgical team. The surgeon and anesthesiologist need to be made aware of the situation so that they can assess the patient's condition and make any necessary adjustments to the surgical procedure or anesthesia delivery. Increasing the flow rate of oxygen (Choice B) may help temporarily but does not address the underlying cause of the oxygen desaturation. Checking the endotracheal tube placement (Choice C) is important but may not be the immediate priority in this critical situation. Assessing the patient's respiratory status (Choice D) is important but should be done after informing the surgeon and anesthesiologist to ensure coordinated and timely interventions.

Correct Answer: C

Rationale: The correct answer is C: Pancreas. The pancreas is responsible for producing digestive enzymes and bicarbonate-rich pancreatic juice. It secretes enzymes like amylase, lipase, and protease to break down carbohydrates, fats, and proteins in the small intestine. The bicarbonate-rich juice helps neutralize stomach acid. The liver (A) produces bile stored in the gallbladder (B), which aids in fat digestion. The spleen (D) is involved in immune function and blood filtration, not digestive enzyme production.

Correct Answer: B

Rationale: The correct answer is B: Lie on the affected area. This position would hinder drainage and increase pressure on the affected area. A: Tilt head to the side if sitting up, is correct as it promotes drainage. C: Putting pillows behind the head can also aid drainage. D: Lying on the non-affected ear can help reduce pressure on the affected side.

Correct Answer: B

Rationale: The primary reason for surgical repair of myelomeningocele is to correct the neurologic defect. This is because myelomeningocele is a type of neural tube defect where the spinal cord and its protective covering do not close properly. Surgical repair aims to close the opening in the spinal cord to prevent further damage, improve neurological function, and reduce the risk of complications such as paralysis and infection. The other choices are incorrect as they are not the primary goal of the surgery. Preventing infection (Choice A) is important but not the primary reason. Seizure disorders (Choice C) and hydrocephalus (Choice D) may be associated complications but are not the main purpose of the surgical repair.