Adult Health Nursing Test Banks

Correct Answer: B

Rationale: Tilt back Claudia's head slightly would have been the correct action to prevent her from blinking during eye drop instillation. By tilting her head back, you create a more stable position for instilling the eye drops, reducing the likelihood of accidental contact with her eyelid. Additionally, tilting the head back slightly helps in making it easier for the drops to enter the eye and stay within the conjunctival sac, improving the efficacy of the medication.

Correct Answer: D

Rationale: When a client experiences cardiac arrest, their breathing may become insufficient, leading to inadequate elimination of carbon dioxide (CO2) from the body. With reduced CO2 elimination, the level of CO2 in the bloodstream increases, causing respiratory acidosis. This imbalance is characterized by a decrease in blood pH along with an increase in CO2 levels in the blood, resulting in an acidic environment. Respiratory acidosis is the most common imbalance seen in clients who have experienced cardiac arrest, as impaired gas exchange impacts the body's ability to maintain proper acid-base balance.

Correct Answer: B

Rationale: In the community setting, the essential record about the patient is the patient's chart. This chart contains all important information about the patient, including medical history, treatment plans, medications, progress notes, and any other pertinent information related to the patient's care. It serves as a crucial document for healthcare providers to track and monitor the patient's health status, facilitate communication among team members, ensure continuity of care, and make informed clinical decisions. The patient's chart is a comprehensive and centralized source of information that guides the delivery of quality care in the community setting.

Correct Answer: D

Rationale: The diagnosis of gestational diabetes mellitus (GDM) is typically confirmed through an oral glucose tolerance test (OGTT) during pregnancy. In GDM, the 2-hour plasma glucose level during the OGTT is equal to or greater than 140 mg/dL. This finding is characteristic of GDM and distinguishes it from other types of diabetes. Fasting blood glucose ?126 mg/dL is diagnostic of diabetes mellitus outside of pregnancy, not specifically GDM. Random plasma glucose ?200 mg/dL is indicative of uncontrolled diabetes in general. Hemoglobin A1c (HbA1c) ?6.5% is used for diagnosing diabetes outside of pregnancy and is not specific to GDM.

Correct Answer: B

Rationale: In a situation where a patient's temperature is dropping below the normal range during surgery, the nurse should prioritize actively warming the patient to prevent hypothermia. Administering a warming blanket or using a forced-air warming device are effective methods to increase the patient's body temperature and prevent any complications that may arise from hypothermia. Increasing the ambient room temperature can help, but it may not be as direct or effective as applying targeted heat sources to the patient. Documenting the temperature trend in the patient's chart is important for record-keeping purposes, but immediate action to address the dropping temperature is necessary. Continuously monitoring the patient's temperature closely is important, but action should be taken promptly to prevent further decline.