Adult Health 1 Exam 1 - Nurselytic

Questions 49

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Adult Health 1 Exam 1 Questions

Question 1 of 5

Which of the following are key parameters that produce blood pressure? (Select ONE that does not apply)

Correct Answer: D

Rationale: Heart rate, stroke volume, and peripheral resistance are indeed key parameters that directly influence blood pressure. Heart rate refers to the number of times the heart beats per minute, affecting how much blood is pumped. Stroke volume is the amount of blood pumped by the heart in one contraction. Peripheral resistance is the resistance of the arteries to blood flow, impacting the pressure needed to push blood through. Neuroendocrine hormones, while they can indirectly influence blood pressure regulation by affecting factors like blood volume and vascular tone, are not direct final parameters that produce blood pressure.

Question 2 of 5

How should the nurse respond to an older male client who states that his religion does not permit him to bathe daily?

Correct Answer: C

Rationale: The correct response is to offer the client several choices of times to bathe during the day. This approach respects the client's religious beliefs while ensuring that hygienic practices are still maintained. By providing options, the nurse can work together with the client to find a solution that aligns with both his beliefs and his health needs.
Choice A is incorrect because solely reviewing the importance of hygiene may not address the client's specific religious concerns.
Choice B is inappropriate as it disregards the client's beliefs and autonomy.
Choice D is not the best approach as it may come off as confrontational or dismissive of the client's beliefs, rather than working collaboratively to find a suitable solution.

Question 3 of 5

Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?

Correct Answer: C

Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.

Question 4 of 5

After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement?

Correct Answer: B

Rationale: Placing a wedge under the client's hip is the correct action in this scenario. This helps relieve the pressure on the vena cava, which can become compressed in the lithotomy position during pregnancy, improving circulation and reducing symptoms like dizziness and pallor. Instructing the client to take deep breaths (
Choice
A) may not address the underlying cause of the symptoms. Placing the client in the Trendelenburg position (
Choice
C) would worsen the situation by further compressing the vena cava. Removing the client's legs from the stirrups (
Choice
D) may provide temporary relief but does not address the root cause of the issue.

Question 5 of 5

A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past hour, 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?

Correct Answer: C

Rationale: The correct intervention for the nurse to implement is to add sterile water to the suction control chamber. This action helps maintain the proper functioning of the chest tube system by regulating the negative pressure. Increasing wall suction is not recommended as it could lead to excessive negative pressure. Giving blood from the collection chamber as autotransfusion is inappropriate and poses a risk of complications such as air embolism. Manipulating blood in the tubing is also unsafe as it could introduce air into the system, increasing the risk of complications for the client.

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