foundations of nursing test bank

foundations of nursing test bank Related

Review foundations of nursing test bank related questions and content

A nurse has asked the nurse educator if there is any way to predict the severity of a patients anaphylactic reaction. What would be the nurses best response?

  • A. The faster the onset of symptoms, the more severe the reaction.
  • B. The reaction will be about one-third more severe than the patients last reaction to the same antigen.
  • C. There is no way to gauge the severity of a patients anaphylaxis, even if it has occurred repeatedly in the past.
  • D. The reaction will generally be slightly less severe than the last reaction to the same antigen.
Correct Answer: C

Rationale: The correct answer is C because the severity of an anaphylactic reaction can vary greatly from one episode to another in the same patient. Anaphylactic reactions are unpredictable and can be influenced by various factors such as the amount of allergen exposure, individual immune response, underlying health conditions, and concurrent medications. Therefore, it is not possible to reliably gauge the severity of a patient's anaphylactic reaction even if it has occurred repeatedly in the past.

Choice A is incorrect because the onset of symptoms alone is not a reliable predictor of the severity of the reaction. Choice B is incorrect as well because there is no set formula to predict that the reaction will be one-third more severe than the patient's last reaction. Choice D is incorrect because stating that the reaction will generally be slightly less severe than the last reaction is also not accurate or supported by evidence.

You may also like to solve these questions

A nurse is completing a nutritional status of a patient who has been admitted with AIDS-related complications. What components should the nurse include in this assessment? Select all that apply.

  • A. Serum albumin level
  • B. Weight history
  • C. White blood cell count
  • D. Body mass index E) Blood urea nitrogen (BUN) level
Correct Answer: A

Rationale: The correct answer is A: Serum albumin level. Serum albumin is an important indicator of nutritional status, as low levels may indicate malnutrition or inflammation commonly seen in AIDS patients. Weight history (B) is also relevant as weight changes can reflect nutritional status. White blood cell count (C) is not directly related to nutritional status. Body mass index (D) is a calculation based on weight and height, not a direct measure of nutritional status. Blood urea nitrogen (E) is a measure of kidney function, not a specific indicator of nutritional status. Therefore, the nurse should primarily focus on assessing the patient's serum albumin level for nutritional status evaluation in this case.

The rate of obesity in the United States has reached epidemic proportions. Morbidity and mortality for both the mother and baby are increased in these circumstances. The nurse caring for the patient with an elevated BMI should be cognizant of these potential complications and plan care accordingly. Significant risks include (Select all that apply.)

  • A. Breech presentation
  • B. Ectopic pregnancy
  • C. Birth defects
  • D. Venous thromboembolism
Correct Answer: A

Rationale: The correct answer is A: Breech presentation. Obesity can lead to a larger fetus, increasing the risk of breech presentation. The rationale is that excess fat can hinder the baby's ability to turn head down. Other choices are incorrect because: B: Ectopic pregnancy is not related to obesity, C: Birth defects can be influenced by maternal health but are not directly linked to obesity, and D: Venous thromboembolism is more associated with immobility and hypercoagulable states rather than obesity.

A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL.

  • A. 1800
  • B. 450
  • C. 900
  • D. 90
Correct Answer: C

Rationale: The correct answer is C (900 mL) because the weight of 900 g corresponds to a blood loss of the same amount in milliliters. Blood density is close to that of water, so 1 g ≈ 1 mL. Therefore, a blood-soaked peripad weighing 900 g indicates a blood loss of 900 mL. Choice A (1800 mL) is incorrect as it doubles the weight instead of converting it to milliliters. Choice B (450 mL) is incorrect as it halves the weight. Choice D (90 mL) is incorrect as it divides the weight by 10, which is too small for the blood loss indicated.

Which findings should the nurse follow up on afterremoval of a catheter from a patient? (Select allthat apply.)

  • A. Increasing fluid intake
  • B. Dribbling of urine
  • C. Voiding in small amounts
  • D. Voiding within 6 hours of catheter removal
Correct Answer: B

Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection.

A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal.
C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem.
D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.

The nurse should recognize the greatest risk for the development of blindness in which of the following patients?

  • A. A 58-year-old Caucasian woman with macular degeneration
  • B. A 28-year-old Caucasian man with astigmatism
  • C. A 58-year-old African American woman with hyperopia
  • D. A 28-year-old African American man with myopia
Correct Answer: A

Rationale: The correct answer is A because macular degeneration is a leading cause of blindness in older adults. The macula is responsible for central vision, crucial for tasks like reading and driving. Macular degeneration can lead to permanent vision loss if not managed promptly. The other choices are less likely to result in blindness: astigmatism, hyperopia, and myopia are refractive errors that can be corrected with glasses or contacts, and they do not typically lead to blindness. The age and condition of the patient are important factors in determining the risk of blindness.

Copyright © 2025 Nokea. All rights reserved.