test bank foundations of nursing

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As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that

  • A. immediate birth is required.
  • B. the patient should be transferred to the critical care unit for closer observation.
  • C. RhoGAM should be administered.
  • D. a tetanus shot should be administered.
Correct Answer: A

Rationale: The correct answer is A: immediate birth is required. The Kleihauer–Betke test is used to detect fetal-maternal hemorrhage in situations where there is a risk of fetal blood entering the maternal circulation, such as trauma during pregnancy. A positive result indicates a significant fetal-maternal hemorrhage, which can lead to Rh incompatibility and severe fetal anemia. Immediate birth is required to prevent complications and ensure the safety of both the mother and the baby.

Choice B is incorrect as transferring the patient to the critical care unit does not address the underlying issue of fetal-maternal hemorrhage. Choice C is incorrect as RhoGAM is typically administered to prevent Rh sensitization in Rh-negative mothers carrying Rh-positive babies, which is not the primary concern in this scenario. Choice D is incorrect as a tetanus shot is not directly related to the positive Kleihauer–Betke test result indicating fetal-maternal hemorrhage.

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The patient is an 80-year-old male who is visiting the clinic today for a routine physical examination. The patient’s skin turgor is fair, but the patient reports fatigue and weakness. The skin is warm and dry, pulse rate is 116 beats/min, and urinary sodium level is slightly elevated. Which instruction should the nurse provide?

  • A. Drink more water to prevent further dehydration.
  • B. Drink more calorie-dense fluids to increase caloric intake.
  • C. Drink more milk and dairy products to decrease the risk of osteoporosis.
  • D. Drink more grapefruit juice to enhance vitamin C intake and medication absorption.
Correct Answer: A

Rationale: The correct answer is A: Drink more water to prevent further dehydration. Given the patient's fair skin turgor, fatigue, weakness, warm and dry skin, elevated pulse rate, and slightly elevated urinary sodium level, these are signs of dehydration. Increasing water intake would help improve the patient's hydration status. Other choices are incorrect because B (calorie-dense fluids) does not address the dehydration issue, C (milk and dairy products) does not directly address the symptoms presented, and D (grapefruit juice) is not essential for hydration in this case.

A pediatric nurse is emotionally distraught by the death of a 9-year-old girl who received care on the unit over the course of many admissions spanning several years. What action is the most appropriate response to the nurses own grief?

  • A. Take time off from work to mourn the death.
  • B. Post mementos of the patient on the unit.
  • C. Solicit emotional support from the patients family.
  • D. Attend the patients memorial service.
Correct Answer: A

Rationale: The correct answer is A because taking time off from work to mourn allows the nurse to process their emotions and prevent burnout. This self-care step promotes mental well-being and helps prevent the nurse from being overwhelmed by their grief.

Choice B is incorrect as it may prolong the grieving process and create a constant reminder of the loss. Choice C could potentially burden the patient's family with the nurse's grief, making it an inappropriate action. Choice D, attending the memorial service, may be emotionally challenging and may not provide the nurse with the necessary space to cope with their grief effectively.

A patient has been prescribed sildenafil. What should the nurse teach the patient about this medication?

  • A. Sexual stimulation is not needed to obtain an erection.
  • B. The drug should be taken 1 hour prior to intercourse.
  • C. Facial flushing or headache should be reported to the physician immediately.
  • D. The drug has the potential to cause permanent visual changes.
Correct Answer: A

Rationale: The correct answer is A because sildenafil works by enhancing the effects of nitric oxide, which is released during sexual stimulation to relax the muscles in the penis and increase blood flow for an erection. Therefore, sexual stimulation is necessary for the medication to be effective.

Explanation of other choices:
B: While sildenafil is typically taken 30 minutes to 4 hours before sexual activity, it does not need to be exactly 1 hour prior.
C: Facial flushing and headache are common side effects of sildenafil but do not require immediate reporting unless severe or persistent.
D: Sildenafil may cause temporary visual disturbances like changes in color vision, but permanent visual changes are rare.

The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. Which action isbestfor the nurseto take?

  • A. Instill nonliquid medications without diluting.
  • B. Irrigate the tube with 60 mL of water after all medications are given.
  • C. Mix all medications together to decrease the number of administrations.
  • D. Check with the pharmacy for availability of the liquid forms of medications.
Correct Answer: D

Rationale: Rationale for Correct Answer (D): Checking with the pharmacy for availability of liquid forms of medications is the best action because it reduces the risk of clogging the nasogastric tube. Liquid medications are less likely to cause blockages compared to nonliquid medications. Additionally, liquid forms are easier to administer through the tube. By using liquid medications, the nurse can ensure that the medications flow smoothly through the tube without causing any obstructions.

Summary of Incorrect Choices:
A: Instilling nonliquid medications without diluting can increase the risk of tube clogging.
B: Irrigating the tube with water after all medications are given may not prevent clogging effectively and could introduce unnecessary moisture into the tube.
C: Mixing all medications together can lead to potential drug interactions and may not address the issue of tube clogging effectively.

A nurse is caring for a patient who just underwentan intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse’sfirstpriorityin caring for this patient?

  • A. Turn the patient on the right side to alleviate pressure on the left kidney.
  • B. Encourage the patient to increase fluid intake to flush the obstruction.
  • C. Monitor the patient for fever, rash, and difficulty breathing.
  • D. Administer narcotic medications to the patient for pain.
Correct Answer: C

Rationale: The correct answer is C: Monitor the patient for fever, rash, and difficulty breathing. The rationale is as follows:
1. Renal calculus obstruction can lead to complications such as infection, so monitoring for fever is crucial.
2. Rash can indicate an allergic reaction to the contrast dye used in the procedure.
3. Difficulty breathing may signal a severe reaction or complications.
Summary:
A: Turning the patient on the right side does not directly address the urgent need to monitor for potential complications.
B: While fluid intake is important, it is not the immediate priority when the patient is at risk of developing complications.
D: Administering narcotic medications may be necessary for pain relief but does not address the potential emergent issues related to the obstruction.

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