Adult Health Nursing Test Banks

Correct Answer: A

Rationale: Checking the flow of oxygen is the priority action because it ensures that Sonny is receiving the correct amount of oxygen prescribed by the healthcare provider. Before connecting the flow meter to the oxygen outlet, turning on the oxygen, or attaching the humidifier, it is crucial to verify that the flow rate is appropriate for Sonny's condition. Monitoring and adjusting the oxygen flow will help maintain the desired oxygen saturation levels and prevent potential complications related to oxygen therapy.

Correct Answer: A

Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.

Correct Answer: B

Rationale: In this scenario, the firm and midline fundus at three hours postpartum indicates that the uterus is contracting well. The presence of a small constant trickle of blood on perineal inspection suggests ongoing bleeding. This combination of findings is concerning for retained placenta, where a portion of the placenta remains attached to the uterine wall and prevents proper contraction and closure of the blood vessels at the placental site. Retained placenta can lead to postpartum hemorrhage and requires prompt evaluation and intervention to prevent complications. Nurse Kayla should escalate this finding to the healthcare provider for further assessment and management.

Correct Answer: A

Rationale: The patient is exhibiting signs and symptoms of alcohol withdrawal, such as tremors, diaphoresis, hyperactivity, elevated blood pressure, and tachycardia. Lorazepam, which is a benzodiazepine, is commonly used to manage alcohol withdrawal symptoms. It helps alleviate symptoms such as anxiety, agitation, tremors, and seizures by acting on the same brain receptors affected by alcohol. It has sedative, anxiolytic, and anticonvulsant properties which can help stabilize the patient and prevent potential complications of alcohol withdrawal, such as seizures. Haloperidol is an antipsychotic medication used for conditions like schizophrenia and acute psychosis; therefore, it would not be appropriate for alcohol withdrawal. Naloxone is used to reverse opioid overdose, and Benztropin is used to treat Parkinson's disease and extrapyramidal symptoms, so they are not indicated for alcohol

Correct Answer: A

Rationale: When handling information about families in the community, the nurse should consider the principle of confidentiality as ethical. Confidentiality refers to the obligation of healthcare providers to safeguard the privacy of patient information. By maintaining confidentiality, the nurse upholds trust and respect in the nurse-family relationship. This principle ensures that sensitive information shared by families is kept secure and not disclosed without permission, thus respecting their autonomy and promoting open communication in healthcare settings.