test bank foundations of nursing

Correct Answer: A

Rationale: The correct answer is A: Ineffective Airway Clearance. In a patient with AIDS and PCP, maintaining clear airways is crucial to prevent respiratory distress and hypoxia. Pneumocystis pneumonia can cause thick secretions and mucus plugging, leading to difficulty breathing. Ensuring effective airway clearance is a priority to optimize oxygenation and prevent respiratory complications. Impaired oral mucous membranes (B) and imbalanced nutrition (C) are important considerations but not as immediate as airway clearance. Activity intolerance (D) may be a concern for the patient but ensuring adequate oxygenation takes precedence.

Correct Answer: C

Rationale: The correct answer is C. Computer competency does not equate to informatics competency. Informatics involves more than just basic computer skills; it encompasses the ability to use technology to manage and analyze data for improved healthcare outcomes. A: This is a correct statement about informatics proficiency. B: This is also a correct statement about the skills needed for informatics. D: This is a true statement about nursing informatics being a recognized specialty, but it does not indicate a need for follow-up. In summary, choice C is incorrect as it oversimplifies the concept of informatics, while choices A, B, and D provide accurate information related to informatics.

Correct Answer: B

Rationale: The correct answer is B. Palpating the area for a breast mass is the most appropriate assessment in this scenario as dimpling of the breast can be a sign of underlying breast abnormalities such as a mass or tumor. By palpating the area, the nurse can determine if there is a lump or any other irregularity that may require further investigation. Choice A is incorrect because evaluating the patient's milk production is not relevant to the presenting symptom of breast dimpling. Choice C is incorrect as assessing the patient's knowledge of breast cancer does not address the immediate need for a physical assessment of the breast dimpling. Choice D is incorrect because assuming that the dimpling is just an age-related change without further assessment could delay potential diagnosis and treatment of a serious condition.

Correct Answer: A

Rationale: The correct answer is A: Obtain an interpreter. This is the best action as it ensures effective communication and accurate understanding of the patient's history and needs. Using a professional interpreter maintains confidentiality, avoids misinterpretation, and promotes cultural sensitivity. Referring to a speech therapist (B) is not appropriate for language barriers. Letting a family member talk (C) may compromise privacy and accuracy. Finding a mental health nurse specialist (D) is not needed for language translation.

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.