TEST BANK FOR ADULT HEALTH NURSING EXAM QUESTIONS WITH RATIONALES LATEST 2024 QUESTIONS WITH CORRECT ANSWERS GRADE A+ A nurse is preparing to teach a client with newly diagnosed chronic kidney disease (CKD) about the disease and its management. The client's ability to learn is dim inished as a result of uremia and anxiety. The nurse makes it a priority to include which when conducting teaching sessions with this client? - CORRECT ANSWER -Family members Rationale: The client with CKD is often faced with such barriers to learning as anxiety and the effects of uremia, including short attention span and memory deficits. The effects of uremia effects usually improve once hemodialysis has begun. The presence of family is helpful, because the family must understand the disease and treatme nt and may help reinforce information with the client after the formal teaching session is over. The presentation of information should be simple, direct, and aimed at the educational level of the client. Charts and diagrams and printed materials may be he lpful but are not the priority. Research articles will not be helpful to the client. A nurse is providing dietary instructions to a client with chronic obstructive pulmonary disease (COPD) who is experiencing a loss of appetite and complains of feeling "too full to eat." What does the nurse encourage the client to do? Select all that apply. - CORRECT ANSWER -Avoid drinking fluids before and during meals Select foods that are easy to chew and are not gas forming Rationale: COPD is a progressive and irreversible condition characterized by diminished inspiratory and expiratory capacity of the lungs. Instruct the client who complains of feeling too full to eat, to avoid drinking fluids before and during the meal. Dry foods such as crackers stimulate coughing; foods such as milk and chocolate may increase the thickness of saliva and secretions. Cheese is constipating and should also be avoided by the client. The nurse should also teach the client about foods that are easy to chew and do not encourage the formation of gas; for this reason, broccoli, which is a gas -forming food, should be avoided. A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection. Forty -eight hours after administration, the nurse checks the test site (see image). - CORRECT ANSWER -Positive Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis (TB) infection. A reaction measuring 5 mm or more in diameter is considered positive in a client with HIV infection. A reaction measuring 10 mm or more in diameter is conside red positive in a non -immunosuppressed client. In this instance, the area of induration measures 9 mm, indicating a positive reaction. A positive reaction does not mean that active disease is present, but it does indicate exposure to TB or the presence of inactive (dormant) disease. A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension. Which findings denote adverse effects of the medication? Select all that apply. - CORRECT ANSW ER -Tall T waves Prolonged PR interval Hyperactive bowel sounds Rationale: Spironolactone is a potassium -sparing diuretic. Potassium -
sparing diuretics can cause hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves, widened QRS complexes, prolonged PR intervals, and flat P waves. Other cardiovascular manifestations include an irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also oc cur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia. A nurse is interpreting a central venous pressure (CVP) reading from a client in whom right ventricular failure has been diagnosed. From this diagnosis, the nurse would expect that the most likely result is a pressure of - COR RECT ANSWER -14 cm H2O Rationale: CVP measurements are used to monitor blood volume and the adequacy of venous return to the heart. The CVP measures pressures from the right atrium or central veins. The normal CVP is 7 to 12 cm H2O. An increased CVP readin g may indicate right ventricular failure. A low CVP reading may indicate hypovolemia. A reading of 4 cm H2O is low. Readings of 8 and 11 cm H2O are normal. A reading of 14 cm H2O is increased. A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way for the nurse to assess the surgical site for bleeding? - CORRECT ANSWER -Checking for moisture on the back of the dressing over the client's neck and shou lders Rationale: Thyroid surgery may be complicated by hemorrhage, respiratory distress, parathyroid gland injury (resulting in hypocalcemia and tetany), damage to the laryngeal nerves, and thyroid storm. Hemorrhage is most likely during the 24 hours after surgery. If the client is bleeding after surgery, gravity will cause the blood to seep down the sides of the dressing and drain onto the underlying bed linens even as the top of the dressing remains clean and dry. Asking the client whether the dressing fe els wet and replacing the dry sterile dressing every 2 hours are not the best actions. Replacing the dressing frequently when it is not warranted could also increase the risk of infection. A client who sustained a major burn injury is beginning to take a n oral diet again. Which between -meal menu selections meet the client's needs for wound healing and tissue repair? Select all that apply. - CORRECT ANSWER -Whole -milk shake and granola
sparing diuretics can cause hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves, widened QRS complexes, prolonged PR intervals, and flat P waves. Other cardiovascular manifestations include an irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also oc cur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia. A nurse is interpreting a central venous pressure (CVP) reading from a client in whom right ventricular failure has been diagnosed. From this diagnosis, the nurse would expect that the most likely result is a pressure of - COR RECT ANSWER -14 cm H2O Rationale: CVP measurements are used to monitor blood volume and the adequacy of venous return to the heart. The CVP measures pressures from the right atrium or central veins. The normal CVP is 7 to 12 cm H2O. An increased CVP readin g may indicate right ventricular failure. A low CVP reading may indicate hypovolemia. A reading of 4 cm H2O is low. Readings of 8 and 11 cm H2O are normal. A reading of 14 cm H2O is increased. A nurse is caring for a client who has just undergone thyroidectomy. Which technique is the best way for the nurse to assess the surgical site for bleeding? - CORRECT ANSWER -Checking for moisture on the back of the dressing over the client's neck and shou lders Rationale: Thyroid surgery may be complicated by hemorrhage, respiratory distress, parathyroid gland injury (resulting in hypocalcemia and tetany), damage to the laryngeal nerves, and thyroid storm. Hemorrhage is most likely during the 24 hours after surgery. If the client is bleeding after surgery, gravity will cause the blood to seep down the sides of the dressing and drain onto the underlying bed linens even as the top of the dressing remains clean and dry. Asking the client whether the dressing fe els wet and replacing the dry sterile dressing every 2 hours are not the best actions. Replacing the dressing frequently when it is not warranted could also increase the risk of infection. A client who sustained a major burn injury is beginning to take a n oral diet again. Which between -meal menu selections meet the client's needs for wound healing and tissue repair? Select all that apply. - CORRECT ANSWER -Whole -milk shake and granola
