Focus on Adult Health Exam 100% Pass Guaranteed All Round Questions and Correct Answers
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Course
Nursing
Institution
Nursing
A client arrives at the emergency department and reports a buzzing sound in his ear. The client
tells the nurse that an insect flew into the ear. Which intervention does the nurse take first to
remove the insect? - CORRECT ANSWER -Instilling lidocaine into the ear
Rationale: Insects that make...
A client arrives at the emergency department and reports a buzzing sound in his ear. The client
tells the nurse that an insect flew into the ear. Which intervention does the nurse take first to
remove the insect? - CORRECT ANSWER ✔✔ -Instilling lidocaine into the ear
Rationale: Insects that make their way into an ear are killed before removal unless they can be
coaxed out with the use of a flashlight or a humming noise. Mineral oil, diluted alcohol, or
lidocaine (not water) is instilled into the ear canal (or an ether-soaked cotton ball is placed in the
ear) to suffocate the insect, which is then removed with the use of ear forceps. When the foreign
object is vegetable matter, irrigation is not used, because this material expands with hydration,
worsening the impaction becomes worse. Antibiotics may or may not be prescribed after removal
of the insect.
A client arrives in the emergency department after sustaining a chemical splash to the eye. The
nurse immediately flushes the eye with copious amounts of normal saline solution for 15 minutes
and then tests the pH of eye, using litmus paper. The nurse should continue the saline flushes
until the pH test reads: - CORRECT ANSWER ✔✔ -7.40
Rationale: First aid after a chemical burn to the eye consists of irrigation of the eye with copious
amounts of tap water for at least 5 minutes. As soon as the initial irrigation is complete, the
victim should be rushed to the nearest medical facility. On arrival, eye irrigation should be
resumed with water or normal saline for 15 to 20 minutes or until all invasive material is gone
and litmus paper reveals a pH of about 7.40. A quick test with litmus can be performed before,
,during, and after irrigations to determine the pH and to ascertain whether the substance was acid
or alkaline. The normal body pH is 7.40.
A client complains of a rapid heartbeat and shortness of breath. While watching the client's
cardiac monitor, the nurse notes the following pattern:
The nurse interprets this finding as: - CORRECT ANSWER ✔✔ -Atrial fibrillation
Rationale: Atrial fibrillation is a dysrhythmia arising when ectopic foci in the atrium discharge
impulses at a rate of 400 beats/min or faster. There are usually no definable P waves; these
impulses are so rapid that they cause the atria to quiver instead of contracting regularly,
producing irregular wavy deflections. Because ventricular depolarization is fairly normal in atrial
fibrillation, the QRS complexes appear normal. Atrial flutter is marked by the "sawtooth"
appearance of P waves that may or may not be regular. Ventricular fibrillation and ventricular
tachycardia do not feature normal QRS complexes.
A client has a prescription to have blood drawn from the radial artery for a set of arterial blood
gas (ABG) determinations. For which test does the nurse look for a positive result before the
blood is drawn? - CORRECT ANSWER ✔✔ -Allen test
Rationale: The Allen test is performed before blood is drawn for assessment of arterial blood
gases. The radial and ulnar arteries are occluded in turn, then released, after which the distal
circulation is assessed. If the result is positive, the client has adequate circulation and that site
,may be used. The Trousseau sign is an indication of the presence of carpopedal spasms, denoting
hypocalcemia. The presence of the Brudzinski sign indicates nuchal rigidity. The Babinski reflex
is used to assess neurological dysfunction.
A client has been taking pyrazinamide (PMS Pyrazinamide) for 2 months. Which culture result
does the nurse monitor as an indicator that the medication may soon be discontinued? -
CORRECT ANSWER ✔✔ -Sputum
Rationale: Pyrazinamide is an antitubercular medication that is given in conjunction with other
antitubercular medications. The prescriber may discontinue its use if sputum cultures become
negative. Urine, blood, and wound cultures are not associated with the use of this medication.
A client hospitalized with an abdominal aortic aneurysm (AAA) suddenly complains of severe
back and flank pain. The nurse notes on the cardiac monitor that the client's heart rate has
increased from 80 to 110 beats/min. The nurse should: - CORRECT ANSWER ✔✔ -
Immediately contact the health care provider
Rationale: The signs and symptoms in the question are indicative of rupture of the AAA. Typical
signs and symptoms of rupture include back and flank pain, ecchymosis of the flank and perianal
areas, a pulsating abdominal mass, lightheadedness, nausea, and signs of shock. This is an
emergency situation, and the client requires simultaneous resuscitation and preparation for
immediate surgical repair. The other options are incorrect and would delay necessary treatment.
, A client infected with HIV has a T4 count of 150/mm3 and a low CD4+/CD8+ ratio. On the
basis of these values, the nurse concludes that the client is: - CORRECT ANSWER ✔✔ -A risk
for opportunistic infection
Rationale: The percentage and number of CD4+ (T4) and CD8+ (T8) cells are an important part
of an immune profile. Individuals with HIV disease usually have a lower-than-normal number of
CD4 cells. The normal CD4+ count is between 500 and 1600 cells/mm3. The normal ratio of
CD4+ to CD8+ cells is approximately 2:1. In HIV infection, because of the low number of CD4+
cells, this ratio is low. A low CD4+ cell count and a low CD4+/CD8+ ratio are associated with
increased incidence of clinical manifestations of the disease, and the client is at risk for
opportunistic infection. The nurse uses this information in planning infection-control measures
for the client. The remaining options are incorrect interpretations.
A client is experiencing frequent premature ventricular contractions (PVCs). To which
assessment would the nurse give priority? - CORRECT ANSWER ✔✔ -Peripheral perfusion
Rationale: Peripheral pulses may be diminished or absent with PVCs because the decreased
stroke volume of the premature beats may decrease peripheral perfusion. It is essential for the
nurse to determine whether the premature complexes are resulting in perfusion. This is done by
palpating the carotid, brachial, or femoral arteries while observing the monitor for widened
complexes or by auscultating for the apical heart sounds. PVCs may be caused by cardiac
disorders or any number of physiological stressors, including infection, illness, surgery, and
trauma, as well as the intake of caffeine, nicotine, or alcohol. Although laboratory results, the
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