foundations of nursing test bank

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.

Correct Answer: B

Rationale: The correct answer is B because the nurse should prioritize the patient who has been receiving total parenteral nutrition (TPN) infusing with the same tubing for 26 hours. This patient needs to be seen first to monitor for any potential complications or issues related to TPN administration. Choice A can be ruled out because 50 hours is longer than 26 hours. Choices C and D involve enteral feeding, which is important but generally less critical than TPN. Additionally, choice D has a shorter duration than choice B. Therefore, choice B is the most time-sensitive and critical patient to assess first.

Correct Answer: A

Rationale: Rationale for Correct Answer A: Applying a protective eye shield at night is crucial for a patient with Bell's palsy to prevent corneal abrasions due to incomplete eyelid closure. This action helps protect the eye from dryness and injury, which can occur due to decreased blinking and moisture. It is essential to maintain eye health and prevent complications. Summary of Incorrect Choices: B: Chewing on the affected side does not prevent unilateral neglect in Bell's palsy. Instead, encouraging balanced chewing and facial exercises would be more beneficial. C: Avoiding the use of analgesics is not necessary for Bell's palsy management unless contraindicated, as pain management may be required for associated symptoms. D: Avoiding brushing the teeth is not recommended. Good oral hygiene is important for overall health, including maintaining oral health during Bell's palsy.

Correct Answer: B

Rationale: Step 1: Immunotherapy injections can cause allergic reactions. Step 2: Monitoring post-injection is crucial to detect and manage any potential adverse reactions promptly. Step 3: Staying in the clinic for 30 minutes allows for immediate intervention if needed. Step 4: This ensures patient safety and reduces the risk of severe reactions. Summary: A: Epinephrine is not typically given before immunotherapy injections. C: Therapeutic response may take longer than 3 months to show. D: Immunotherapy is usually given via subcutaneous route, not intravenous.

Correct Answer: C

Rationale: The correct answer is C. Cholesteatomas are often the result of chronic otitis media. Chronic otitis media can lead to the formation of cholesteatomas, which are noncancerous but can cause complications if left untreated. Cholesteatomas do not resolve spontaneously (A), are not the result of metastasis (B), do not typically cause intractable neuropathic pain (D), and usually require surgical removal to prevent complications (E). Therefore, educating the patient about the association between chronic otitis media and cholesteatoma is essential for understanding the diagnosis and potential treatment options.