Adult Health Final Exam 3 And All Correct Answers.
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Course
Collaborative Adult Health
Institution
Collaborative Adult Health
A 19-yr-old woman admitted with anorexia nervosa is 5 ft, 6 in (163 cm) tall and weighs 88 lb (41 kg). Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which patient problem has the highest priority?
a. Risk for electrolyte imbalance
b. Disturbed body image
c. Impaired nutritional...
Adult Health Final Exam 3 And All
Correct Answers.
A 19-yr-old woman admitted with anorexia nervosa is 5 ft, 6 in (163 cm) tall and weighs 88 lb (41 kg).
Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which patient problem has the highest
priority?
a. Risk for electrolyte imbalance
b. Disturbed body image
c. Impaired nutritional status
d. Difficulty coping - Answer The correct answer is: Risk for electrolyte imbalance
The patient's hypokalemia may lead to life-threatening cardiac dysrhythmias. The other diagnoses are
also appropriate for this patient but are not associated with immediate risk for fatal complications.
After sleeve gastrectomy, a 42-yr-old male patient returns to the surgical nursing unit with a nasogastric
tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control.
Which nursing action should be included in the postoperative plan of care?
a. Support the surgical incision during patient coughing and turning in bed.
b. Remind the patient that PCA use may slow the return of bowel function.
c. Offer sips of fruit juices at frequent intervals.
d. Irrigate the nasogastric (NG) tube frequently. - Answer The correct answer is: Support the surgical
incision during patient coughing and turning in bed.
Protecting the incision from strain decreases the risk for wound dehiscence. The patient should be
encouraged to use the PCA because pain control will improve the cough effort and patient mobility. NG
irrigation may damage the suture line or overfill the stomach pouch. Sugar-free clear liquids are offered
during the immediate postoperative time to decrease the risk for dumping syndrome.
A patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action
will be included in the plan of care?
a. Instruct the patient to cough every hour.
b. Deflate the gastric balloon if the patient reports nausea.
,c. Monitor the patient for shortness of breath.
d. Verify the position of the balloon every 4 hours. - Answer The correct answer is: Monitor the patient
for shortness of breath.
The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the
gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing
increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after
insertion and does not require further verification. Balloons may be deflated briefly every 8 to 12 hours
to avoid tissue necrosis, but if only the gastric balloon is deflated, the esophageal balloon may occlude
the airway. Balloons are not deflated for nausea.
Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced
cirrhosis?
a. The patient's bilirubin level decreases.
b. The patient denies nausea or anorexia.
c. The patient has at least one stool daily.
d. The patient is alert and oriented. - Answer The correct answer is: The patient is alert and oriented.
The purpose of lactulose in the patient with cirrhosis is to lower ammonia levels and prevent
encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this
patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.
Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who
has acute pancreatitis?
a. Calcium
b. Lipase
c. Bilirubin
d. Potassium - Answer The correct answer is: Lipase
Lipase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not
be useful in evaluating whether the prescribed therapies have been effective.
, A patient has been admitted with acute liver failure. Which assessment data are most important for the
nurse to communicate to the health care provider?
a. Liver 3 cm below costal margin
b. Elevated total bilirubin level
c. Jaundiced sclera and skin
d. Asterixis and lethargy - Answer The correct answer is: Asterixis and lethargy
The patient's findings of asterixis and lethargy are consistent with grade 2 hepatic encephalopathy.
Patients with acute liver failure can deteriorate rapidly from grade 1 or 2 to grade 3 or 4 hepatic
encephalopathy and need early transfer to a transplant center. The other findings are typical of patients
with hepatic failure and would be reported but would not indicate a need for an immediate change in
the therapeutic plan.
A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highestpriority on
assisting the patient to:
a. ambulate the evening of the operative day.
b. turn, cough, and deep breathe every 2 hours.
c. choose preferred low-fat foods from the menu.
d. perform leg exercises hourly while awake. - Answer The correct answer is: turn, cough, and deep
breathe every 2 hours.
Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications
because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other
nursing actions are also important to implement but are not as high a priority as ensuring adequate
ventilation.
What should the nurse include when teaching an adult patient to prevent the recurrence of kidney
stones?
a. Using a filter to strain all urine
b. Avoiding dietary sources of calcium
c. Choosing diuretic fluids such as coffee
d. Drinking 3000 mL of fluid each day - Answer The correct answer is: Drinking 3000 mL of fluid each
day
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