Foundations and Adult Health Nursing Test Bank

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A patient receiving palliative care for end-stage lung disease experiences dyspnea and anxiety. What intervention should the palliative nurse prioritize to address the patient's symptoms?

  • A. Administer supplemental oxygen therapy to improve oxygenation.
  • B. Teach the patient diaphragmatic breathing exercises for respiratory support.
  • C. Prescribe benzodiazepine medications to reduce anxiety and promote relaxation.
  • D. Refer the patient to a pulmonologist for evaluation and treatment of dyspnea.
Correct Answer: B

Rationale: Teaching the patient diaphragmatic breathing exercises for respiratory support would be the most appropriate intervention to address the symptoms of dyspnea and anxiety in this scenario. Diaphragmatic breathing, also known as belly breathing, focuses on engaging the diaphragm for deep, slow breaths, which can help improve lung expansion and ventilation. This technique can help the patient manage their breathing difficulty and reduce anxiety by promoting relaxation and improving oxygen exchange in the lungs. It empowers the patient with a coping strategy they can use independently to alleviate distressing symptoms at any time. Administering oxygen therapy may be beneficial, but the priority is to teach the patient a technique they can use proactively and routinely. Prescribing benzodiazepines should be considered as an adjunct if non-pharmacological interventions are ineffective in managing anxiety. Referring to a pulmonologist may be necessary for comprehensive evaluation and treatment but may not directly address the immediate symptoms of dyspnea and anxiety.

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A patient expresses confusion about their medication regimen. What is the nurse's best approach to address this issue?

  • A. Provide the patient with written instructions only.
  • B. Explain the medication regimen using complex medical terminology.
  • C. Use a teach-back method to assess understanding and clarify any misconceptions.
  • D. Dismiss the patient's concerns and reassure them that the medication is safe.
Correct Answer: C

Rationale: The nurse's best approach to address the patient's confusion about their medication regimen is to use a teach-back method to assess understanding and clarify any misconceptions. This method involves the nurse asking the patient to explain in their own words how they will take their medications, what each medication is for, and any potential side effects they should watch for. By using the teach-back method, the nurse can confirm the patient's comprehension and correct any misunderstandings in a supportive and non-judgmental manner. This approach promotes patient education, empowerment, and adherence to the medication regimen. Providing written instructions alone (Choice A) may not be sufficient if the patient has difficulty reading or understanding written information. Explaining the medication regimen using complex medical terminology (Choice B) can further confuse the patient, making it harder for them to grasp the information. Dismissing the patient's concerns and reassuring them that the medication is safe (Choice D) does not address the root of the issue and

Nurse Bea recall the theory or Nursing as caring by ______.

  • A. Orem
  • B. Kings
  • C. Watson
  • D. Benners
Correct Answer: C

Rationale: The theory of Nursing as Caring was developed by Dr. Jean Watson, a renowned nurse theorist and professor. Watson's Theory of Human Caring focuses on the importance of the nurse-patient relationship, emphasizing the significance of caring in promoting healing and promoting holistic well-being. This theory emphasizes the humanistic aspects of nursing care and highlights the nurse's role in fostering a caring environment that encompasses physical, emotional, social, and spiritual dimensions. Watson's theory emphasizes the importance of empathy, compassion, and authentic presence in nursing practice, making it a valuable framework for guiding nursing care and promoting healing outcomes.

A patient receiving palliative care for end-stage renal disease expresses distress over changes in body image due to edema and weight gain. What intervention should the palliative nurse prioritize to address the patient's concerns?

  • A. Encourage the patient to focus on accepting their body changes as part of the illness.
  • B. Provide education on dietary modifications to manage fluid retention and edema.
  • C. Offer emotional support and validate the patient's feelings about body image changes.
  • D. Prescribe diuretic medications to reduce fluid retention and alleviate edema.
Correct Answer: C

Rationale: The most appropriate intervention for the palliative nurse to prioritize in this situation is to offer emotional support and validate the patient's feelings about body image changes. End-stage renal disease can lead to significant physical changes such as edema and weight gain, which can impact a patient's body image and self-esteem. By providing emotional support and validating the patient's feelings, the nurse can help address the patient's distress and concerns, improving their overall psychological well-being. While providing education on dietary modifications (choice B) and prescribing diuretic medications (choice D) may be important aspects of managing fluid retention and edema, addressing the patient's emotional distress and body image concerns should be the initial priority in a palliative care setting. Encouraging the patient to accept their body changes (choice A) may overlook the emotional impact these changes have on the patient, making choice C the most appropriate intervention.

Which of the following nursing actions should the nurse TEACH the patient's care giver regarding tracheostomy care?

  • A. Remove the tracheostomy tube if obstruction occurs
  • B. Leave the tracheostomy ties in place until the physician change them
  • C. Remove and clean the inner cannula daily
  • D. Never put a covering over the tracheostomy stoma
Correct Answer: C

Rationale: Cleaning the inner cannula daily helps prevent the accumulation of secretions and debris, which can lead to blockages and infections. It is an essential aspect of tracheostomy care to maintain the patency of the airway and prevent complications. Caregivers should be taught how to safely remove, clean, and reinsert the inner cannula as part of routine tracheostomy care.

A nurse is preparing to perform a tracheostomy tube change for a patient. What action should the nurse prioritize to ensure patient safety during the procedure?

  • A. Using sterile technique during the tube change
  • B. Administering sedation to the patient before the procedure
  • C. Skipping the suctioning step to minimize patient discomfort
  • D. Changing the tracheostomy ties after completing the tube change
Correct Answer: A

Rationale: The nurse should prioritize using sterile technique during the tracheostomy tube change to ensure patient safety. Tracheostomy procedures involve a direct entry into the airway, making it crucial to prevent infection and reduce the risk of complications. Sterile technique, including proper hand hygiene, wearing sterile gloves, and using sterile equipment, helps minimize the introduction of pathogens into the patient's airway, reducing the risk of infection. By maintaining a sterile field, the nurse can protect the patient from potential harm and promote a successful outcome of the tracheostomy tube change.

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