Adult Health Nursing Flashcards

A patient with a hip fracture is being assessed for fat embolism syndrome. Which triad of findings is classic?

Answer: Hypoxia, neurological changes, and petechial rash

Fat embolism syndrome classically presents with the triad of hypoxemia (from lung fat emboli), neurological deterioration (confusion, decreased consciousness), and petechial rash (from fat emboli in dermal capillaries), typically 24–72 hours after long-bone fracture.

Which action prevents dumping syndrome in a post-gastrectomy patient?

Answer: Eat small, frequent meals; avoid fluids with meals; lie down after eating

Dumping syndrome occurs when food moves too quickly into the small intestine. Small, frequent, low-carbohydrate meals, avoiding fluids during meals, and lying down after eating slow gastric emptying and reduce symptoms.

A patient develops sudden confusion, tachycardia, and fever of 39.5°C on post-operative day 2. What should the nurse suspect?

Answer: Infection or sepsis

New onset confusion, fever >38°C, and tachycardia are components of systemic inflammatory response syndrome (SIRS), suggesting early sepsis. Post-operative infection typically manifests day 2–5. Immediate assessment and physician notification are required.

What is the priority assessment for a patient with a cervical spinal cord injury?

Answer: Airway patency and respiratory function

Cervical spinal cord injuries at C3–C5 can impair or eliminate phrenic nerve function, causing diaphragmatic paralysis and respiratory failure. Airway and breathing assessment is the absolute priority (ABCs).

Which insulin type has the longest duration of action?

Answer: Glargine (Lantus)

Insulin glargine (Lantus) is a long-acting basal insulin with duration of approximately 20–24 hours and no pronounced peak, providing steady background insulin coverage. It is given once daily.

A patient is prescribed morphine for pain. Which side effect requires the most immediate intervention?

Answer: Respiratory depression with rate <10 breaths/min

Respiratory depression is the most life-threatening opioid side effect. A respiratory rate below 10 breaths/min requires immediate intervention with naloxone (opioid antagonist) and supportive airway measures. Other side effects, while uncomfortable, are not immediately life-threatening.