Adult Health Nursing Flashcards

A patient with COPD is receiving oxygen therapy. What is the safest initial oxygen flow rate?

Answer: 1–2 L/min via nasal cannula

Patients with COPD may rely on hypoxic drive to breathe. High-flow oxygen can suppress this drive and cause respiratory depression. Low-flow oxygen (1–2 L/min) targeting SpO2 of 88–92% is the safe starting point.

Which nursing assessment is most important for a patient receiving heparin therapy?

Answer: Monitor for signs of bleeding and check aPTT values

Heparin is an anticoagulant that increases bleeding risk. Monitoring aPTT (target 1.5–2.5 times control), observing for hematuria, melena, petechiae, and excessive bruising are essential safety assessments.

A post-operative patient reports sudden onset of chest pain and dyspnea on day 3. What should the nurse suspect first?

Answer: Pulmonary embolism

Sudden pleuritic chest pain and dyspnea in a post-operative patient on day 2–5 is a classic presentation of pulmonary embolism from deep vein thrombosis. Immobility, surgery, and hypercoagulable state (Virchow's triad) are risk factors.

What is the primary goal of nasogastric tube decompression after abdominal surgery?

Answer: Remove gas and fluids to prevent abdominal distension and vomiting

Postoperative ileus causes accumulation of gas and secretions in the stomach and intestines. NG decompression removes these contents, reducing distension, nausea, vomiting, and risk of aspiration.

A patient's wound culture reveals MRSA. What precautions are required?

Answer: Contact precautions: gloves and gown for all patient contact

MRSA (methicillin-resistant Staphylococcus aureus) is transmitted via direct contact with the patient or contaminated surfaces. Contact precautions (gloves and gown) are required to prevent spread to other patients.

Which assessment is most important when a patient is receiving a blood transfusion?

Answer: Vital signs every 15 minutes for the first hour

Transfusion reactions can occur within the first 15 minutes. Vital signs (temperature, BP, pulse, respiratory rate) are monitored every 15 minutes during the first hour to detect early signs of hemolytic or febrile reactions.