WGU 454 EXAM 3 ADULT HEALTH 131
QUESTIONS WITH VERIFIED ANSWERS LATEST
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. - CORRECT ANSWER 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
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. -
CORRECT ANSWER 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.
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.
- CORRECT ANSWER 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.
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. - CORRECT ANSWER 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.
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. - CORRECT ANSWER 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
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. - CORRECT ANSWER 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
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. - CORRECT ANSWER 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.
The correct answer is: Drinking 3000 mL of fluid each day
A fluid intake of 2000 to 3000 mL/day is recommended to help flush out minerals
before stones can form. Avoidance of calcium is not usually recommended for
QUESTIONS WITH VERIFIED ANSWERS LATEST
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. - CORRECT ANSWER 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
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. -
CORRECT ANSWER 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.
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.
- CORRECT ANSWER 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.
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. - CORRECT ANSWER 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.
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. - CORRECT ANSWER 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
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. - CORRECT ANSWER 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
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. - CORRECT ANSWER 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.
The correct answer is: Drinking 3000 mL of fluid each day
A fluid intake of 2000 to 3000 mL/day is recommended to help flush out minerals
before stones can form. Avoidance of calcium is not usually recommended for
