AH, Adult health 1 study guide, ADULT HEALTH D444 Complete with 100% accurate solutions + rationales

What does Chron's disease affect?

small bowel/intestine

The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4- years and a surgical repair of a fractured tibia at age 20. The nurse is preparing to set up the oxygen administration and apply a simple face mask. Mark whether the assessment findings indicate that the treatment was effective or ineffective assessment findings.

Ronchi in the right lung - ineffective,

PaCO2 55 mm Hg on a blood gas ineffective,

Diminished breath sounds in the right lung- ineffective.

Symmetric chest expansion-effective,

Oxygen saturation greater than 94%- effective:

Client ambulates without shortness of breath- effective,

The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4- years and a surgical repair of a fractured tibia at age 20. The nurse is preparing to set up the oxygen administration and apply a simple face mask. Which technique should the nurse use when assessing the client for early signs of rheumatoid arthritis?

Observe the client's fingers

Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

Administer a stool softener.

The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4- years and a surgical repair of a fractured tibia at age 20. The nurse is preparing to set up the oxygen administration and apply a simple face mask. What should the nurse do before applying the face mask? Select all that apply.

* Perform hand hygiene,

* Identify the client using Z client identifiers,

* Check the skin around the face,

* Don gloves,

* Assess respiratory function

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

Hematemesis (vomiting blood)

Pneumonia signs and symptoms

* Altered mental status (restlessness , agitation, confusion)

* Fever (over 100.4F/38C)

* Productive cough (yellow sputum/phlegm)

* Fine or coarse crackles / wheezing

* Dyspnea

* Pleuritic chest pain (sharp pain when coughing; report to HCP)

* Low 02 saturation

The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4- years and a surgical repair of a fractured tibia at age 20. The nurse is preparing to set up the oxygen administration and apply a simple face mask. What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

*Encourage the client to take breaks from the oxygen mask every few hours.

*Assist the client in ambulating safely

*Positioning the client with the head of the bed elevated

The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4- years and a surgical repair of a fractured tibia at age 20. The nurse is preparing to set up the oxygen administration and apply a simple face mask. What orders would the nurse question? (Select all that apply.)

* Ibuprofen 400 mg every 4 to 6 hours PRN for temperature greater than 100.5°F

* Supplemental oxygen 10 L/min via nasal cannula

The nurse is planning to care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

Prevent esophageal reflux

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

Topical corticosteroids

The healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 mL of DW to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? * (Always round to the nearest whole number gtt/min.)

38gtt/min

A client who has had a laryngectomy and tracheostomy frequently expects copious amounts of purulent secretions. When changing the lines of the tracheostomy tube, which action is most important for the nurse to take?

Leave the old ties in place until the new ones are secure

A client presents to the emergency department vomiting dark brown emesis and in severe abdominal pain. The client reports to the nurse of recently being diagnosed with adenocarcinoma of the small intestine. After auscultating bowel sounds and obtaining vital signs, which prescription should the nurse implement next?

Insert a nasogastric tube (NGT) and attach to low intermittent suction

A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

improved cognitive function and mental status

Lactulose- works by reducing serum ammonia levels through the promotion of ammonia excretion in the feces, leading to improved cognitive function and mental status in individuals with hepatic encephalopathy

The client with Clostridium diff in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

Check serum creatinine

An older adult client is hospitalized with a fractured femur. During a routine nursing assessment, the client repeatedly asks the nurse to "speak up" so that the client can hear the questions. Which action is best for the nurse to take?

Decrease speaking speed

An adult client is admitted with AIDS and oral Candide albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?

Provide a soft-bristled toothbrush for the client to use during oral care.

In the case of oral candidiasis, using a toothbrush with soft bristles is essential to prevent further irritation and damage to the already compromised oral mucosa.

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

Describe the use of an elimination diet to find trigger food`

A client has a nasogastric (NG) tube placed during abdominal surgery. During postoperative convalescence, the nurse identifies that the client is manifesting a hand tremor, muscle twitching, and confusion. Which arterial blood gases consistent with metabolic alkalosis should the nurse report to the healthcare provider?

pH 7.46,

PCO2 55 mm Hg,

HCO3 36 mEq/L,

PO2 95 mm Hg 50%

A client receives a prescription for vancomycin 500 mg IV every 8 hours. The medication is provided in "500 mg per 100 mL of dextrose 5% in water." To administer the medication for over an hour, the nurse should set the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

100 ml/hr

Vancomycin dosage: 500 mg Concentration of vancomycin solution: 500 mg per 100 mL Total volume of solution for each dose: 100 mL (since the concentration is 500 mg per 100 mL) To administer 500 mg of vancomycin, we need 100 mL of the solution. To administer the medication for over 1 hour, we need to deliver the entire 100 mL over 1 hour. Therefore, the infusion rate (in mL/hr) would be 100 mL/hr

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

Review food labels for sodium content

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea, and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

Obtain a pulse oximetry (oxygen) reading

An adult client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?

Suction to clear secretions from the airway.

A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?

I should use this medication in its hand inhaler every day

A teenage client is admitted to the emergency department following a bee sting. The client arrives with a body rash and 30 minutes later becomes short of breath. The nurse obtains the client's vital signs as a heart rate of 130 beats/minute, respirations of 40 breaths/minute, and a blood pressure of 90/52 mm Hg. The client is exhibiting clinical manifestations of which type of immune reaction?

IgE response hypersensitivity

A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, a productive cough with thickened, tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?

Increase the daily intake of oral fluids to liquefy secretions.

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client's serum laboratory values is most important for the nurse to review?

Hemoglobin

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Culture for sensitive organisms

An adult client with multiple sclerosis (MS) fell while walking to the bathroom. On transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

Complete head-to-toe neurological assessment. (should be to assess and stabilize the patient's immediate medical needs)

A client with cholelithiasis lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

Yellow sclera (yellow eyes)

cholelithiasis = gallstone

Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

Escort the client to the cafeteria

(problems w/motor impairments &difficulties with coordination & balance)

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

High levels of carbon dioxide have accumulated in the blood 34. The nurse is admitting a client with possible tuberculosis

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

Sputum culture positive for Mycobacterium tuberculosis

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety and a hoarse voice. Which nursing problem is the priority for this client?

Risk for aspiration related to difficulty swallowing.

A client is being cared for in the emergency department with acute abdominal pain and a provisional diagnosis of pancreatitis. The nurse assesses the client and obtains the results from laboratory studies. Which information is most valuable in reporting the client's status to the healthcare provider?

Severity of nausea and vomiting and serum amylase results

A client receives a prescription for ophthalmic ketorolac, Prior to administering the medication, the nurse should review the medical record for which condition?

corneal abrasion

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 test- ing.Which action is most important for the nurse to take?

Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE)

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori infection. Prior to administering the H. pylori treatment regimen, the nurse should review the electronic medical record for which medication?

Aspirin (NSAID)

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?

Difficulty with urination

( pyridostigmine = cholinergic muscle stimulant)

(myasthenia gravis = muscle weakness)

When performing postural drainage on a client with chronic ob- structive pulmonary disease (COPD), which approach should the nurse use?

Explain that the client may be placed in five positions. Instruct the client to breathe shallow and fast.

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

For long-term control of normal eye pressure.

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

Provide an eye shield to be worn while sleeping

Day1 The client is a 65-year-old male admitted to the medical surgical unit after a total cholecystectomy. He has a past medical history of hypertension, heart failure, type 1 diabetes mellitus, cholelithiasis, and cigarette smoking 1 pack a day for 20 years. The client has been reporting pain that is "barely relieved by pain medication." He has not been able to use the incentive spirometer (15) every hour as ordered because "it is too painful to take a deep breath.

Day 2 Post-operative Client has a fever. He reports he had a shaking chill and a productive cough episode early in the morning but didn't want to bother the night nurse. The client states " I cannot lie down to sleep because I can't stop coughing." He also reports he has chest pain to the right-side rating 6 on a pain scale of 0 to 10. Which physician orders would the nurse anticipate being prescribed after reporting findings? (Select all that apply).

* Start the client on antibiotic therapy,

* STAT complete blood count (CBC),

* basic metabolic panel (BMP),

* blood cultures,

* Send sputum for culture & and sensitivity

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

Primes the inhaler with 7 pumps.

The nurse is discussing dietary choices with a client who is newly diagnosed with celiac disease. Which menu choice by the client indicates a need for further teaching?

Oatmeal (NO B.R.O.W)

The healthcare provider prescribes interferon beta-1b 0.125 mg every other day for a client with multiple sclerosis. The nurse reconstitutes the single-use vial of powder labeled, "0.3 mg with 2 mL of sterile water." How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

0.5mL

Volume= (prescribed dose in mg)/ (concentration in mg/mL) to administer in mL. 0.125 mg / 0.3 mg/2mL =

A client with emphysema reports difficulty breathing and exhibits audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants Immediate intervention by the nurse?

irregular, rapid heartbeat

Three days after a cholecystectomy for cholelithiasis, a client reports persistent upper abdominal pain that radiates to the back. The client has vomited three times in the last 12 hours and has a temperature of 101.8°F (38.7° C). Serum amylase and lipase are twice the normal value. Based on these findings, the nurse should observe the client for which pathophysiological condition?

Acute pancreatitis

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Auscultate the client's bowel sounds

Influenza symptoms

Referral to healthcare provider for oseltamivir prescription

The nurse is preparing a teaching plan for a group of clients who were found to be HIV positive within the last year. Members of the group express an interest in learning about the pathology of AIDS. The nurse should explain that HIV acts in which way to suppress the immune system?

Destruction of helper T-cells and CD4 cells.

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow- up action by the nurse?

Review with the client the need to avoid foods that are rich in milk and cream

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Draw air in through the nose and exhale slowly through pursed lips

To assess the quality of an adult client's pain, which approach should the nurse use?

Ask the client to describe the pain

A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

Advise the client that healing typically takes several weeks to occur.

The antitubercular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness of this medication, which outcome can the nurse expect this client to exhibit?

Decreased cough and sputum

A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?

Refer the client to the healthcare provider at the clinic to obtain a medication prescription

Appendix location

right lower quadrant of stomach

Appendicitis (4)

inflamed appendix that can cause abdominal pain, nausea, and fever

Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?

Use of Alcohol/Alcoholism

The patients Hemoglobin A1c today of 8.29% & was 7.59% there months ago. [Reference range 4 to 5.99] What diagnosis?

Diabetes mellitus

Duodenal ulcer

Avoiding dairy products rich in milk and cream

Emphysema

Improving gas exchange by pursed lip breathing

Erosive esophagitis

Educating on healing time after lansoprazole use

Isoniazid

Expectation of decreased cough and sputum in TB treatment

Common cold symptoms

scratchy throat, nasal discharge, malaise, headache, cough

ER for abdominal pain

gallstones , fluid, pain

pneumonia

ct scan, x ray , albuterol , fluids

gunshot wound

surgery , fluids, NG tube

The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4- years and a surgical repair of a fractured tibia at age 20. The nurse is preparing to set up the oxygen administration and apply a simple face mask.The orders would the nurse question? (Select all that apply.)

Ibuprofen 400 mg every 4 to 6 hours PRN for temperature greater than 100.5°F,Supplemental oxygen 10 L/min via nasal cannula

The client is a 51-year-old male with pneumonia. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4- years and a surgical repair of a fractured tibia at age 20. The nurse is preparing to set up the oxygen administration and apply a simple face mask.SATA

Perform hand hygiene, Identify the client using Z client identifiers, Check the skin around the face, Don gloves, Assess respiratory function

A client with myasthenia gravis (muscle weakness)receives a new prescription for pyridostigmine(cholinergic muscle stimulant). Which information should the nurse obtain to prior to administering the medication?

Difficulty with urination

A client with cholelithiasis(gallstone) lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

Yellow sclera(yellow eyes)

Which approach is best for the nurse to use when directing a client with Huntington's disease(problems w/motor impairments &difficulties with coordination & balance) to the hospital cafeteria?

Escort the client to the cafeteria

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing.Which action is most important for the nurse to take?

Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE)

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection. Prior to administering the H. pylori treatment regimen, the nurse should review the electronic medical record for which medication?.

Aspirin(NSAIDS)

The nurse is discussing dietary choices with a client who is newly diagnosed with celiac disease( no wheat or gluten). Which menu choice by the client indicates a need for further teaching?

Oatmeal

The healthcare provider prescribes interferon beta-1b 0.125 mg every other day for a client with multiple sclerosis. The nurse reconstitutes the single-use vial of powder labeled, "0.3 mg with 2 mL of sterile water." How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)\ Volume= (prescribed dose in mg) / (concentration in mg/mL) to administer in mL. 0.125 mg / 0.3 mg/2mL = 0.5 mL

0.5 mL correct answer

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete

Auscultate the client's bowel sounds.

A client who is experiencing respiratory distress is admitted with respiratory acidosis.

Which pathophysiological process supports the client's respiratory acidosis?

High levels of carbon dioxide have accumulated in the blood.

A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to

the intensive care unit, the client is confused and has had projectile vomiting twice.

Which intervention should the nurse implement first?

Complete head-to-toe neurological assessment.

A client has been administered lactulose for several days. Which therapeutic response

should the nurse expect for a client with hepatic encephalopathy?

Improved mental status.

A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?

Increase the daily intake of oral fluids to liquefy secretions.

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

Obtain a pulse oximetry reading.

Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

Observe the client's fingers.

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE).

A client with emphysema is reporting difficulty in breathing and exhibiting audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

Irregular rapid heart rate.

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

Check serum creatinine.

A client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?

Suction to clear secretions from airway.

A client has a nasogastric (NG) tube placed during abdominal surgery. During postoperative convalescence, the nurse identifies that the client is manifesting a hand tremor, muscle twitching, and confusion. Which arterial blood gas values are consistent with metabolic alkalosis that the nurse should report to the healthcare provider?

pH 7.49, PCO2 45 mm Hg, HCO3 32 mEq/L (32 mmol/L), PO2 90 mm Hg.

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Apply a hydrocolloidal gel dressing.

An adult client is admitted with AIDS and oral Candida albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?

Provide a soft-bristled toothbrush for the client to use during oral care.

A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

Yellow sclera.

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with H. pylori. Prior to administering the H. pylori treatment regimen, the nurse should review the client's medication list for which medication?

Aspirin.

A client receives a prescription for vancomycin 500 mg IV every 8 hours. The medication is provided in "500 mg per 100 mL of dextrose 5% in water.". To administer the medication over an hour, the nurse should set the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

100 ml/hr

The nurse is preparing a teaching plan for a group of well-educated clients who were found to be HIV positive within the last year.

The nurse should explain that the human immunodeficiency virus (HIV) acts in which way to suppress the immune system?

Destruction of helper T-cells and CD4 cells.

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow-up action by the nurse?

Review with the client the need to avoid foods that are rich in milk and cream.

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

Leave the old ties in place until the new ones are secure.

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

Prevent esophageal reflux.