Adult Health Nursing Answer Key

Correct Answer: B

Rationale: The stomach is responsible for producing hydrochloric acid and intrinsic factor. Hydrochloric acid helps in the breakdown of proteins during digestion, while intrinsic factor aids in the absorption of vitamin B12 in the small intestine. These two components are crucial for the proper functioning of the digestive system, particularly in breaking down food and absorbing essential nutrients. The liver is involved in bile production, the pancreas in the production of digestive enzymes, and the small intestine in nutrient absorption, but the specific functions related to hydrochloric acid and intrinsic factor are primarily attributed to the stomach.

Correct Answer: A

Rationale: ORNAP stands for Operating Room Nurses Association of the Philippines. As Merle has been assigned in the Operating Room for 3 years and is interested in actively joining a professional organization related to this field, ORNAP would be the most appropriate choice. ORNAP focuses on promoting excellence in perioperative nursing practice through education, research, and collaboration. By joining ORNAP, Merle can further enhance her knowledge and skills in the Operating Room setting, as well as network with other professionals in the same field.

Correct Answer: B

Rationale: Spironolactone is a potassium-sparing diuretic commonly used in the management of heart failure. One of the significant side effects of spironolactone is hyperkalemia, which is an elevated level of potassium in the bloodstream. Spironolactone works by blocking the action of aldosterone, a hormone that regulates potassium and sodium balance in the body. By inhibiting aldosterone, spironolactone reduces potassium excretion in the urine, leading to potential accumulation of potassium in the body.

Correct Answer: B

Rationale: The nurse's priority action after applying the surgical dressing is to assess the surgical incision for signs of complications. This includes checking for any signs of infection, excessive bleeding, or other complications related to the surgical site. Early detection of such complications is crucial for ensuring proper healing and preventing serious complications. Once the assessment is done and any issues are addressed, the nurse can proceed with documenting the dressing change, providing instructions to the patient about wound care, and ensuring that the dressing is securely and correctly applied.

Correct Answer: C

Rationale: When conducting a nursing history on the Health Perception, Health Management pattern of functioning pre-operatively, an appropriate question to ask would be "Are you aware of risk factors for your disease?" This question helps assess the individual's level of awareness and understanding of their health condition and the factors that may impact it. Understanding the patient's knowledge of their risk factors can help guide interventions and education before surgery to optimize their health outcomes. Asking about perceived wound healing, shortness of breath, or weight changes may not be directly related to the patient's awareness of their disease risk factors in the pre-operative setting.