foundations of nursing test bank

Correct Answer: A

Rationale: The correct answer is A: Ewald tube. This tube is used for gastric lavage due to its large diameter and open end which allows for effective suction of gastric contents. The Ewald tube is specifically designed for gastric lavage and is ideal for removing toxins from the stomach. Summary of why the other choices are incorrect: B: Dobhoff tube is a small-bore feeding tube, not suitable for gastric lavage. C: Miller-Abbott tube is used for intestinal decompression, not gastric lavage. D: Sengstaken-Blakemore tube is used for esophageal varices, not gastric lavage.

Correct Answer: C

Rationale: The correct answer is C: "You are anxious about the surgery. Do you see smoking as helping?" This response acknowledges the patient's anxiety and invites him to explore his reasons for wanting to smoke, opening up a dialogue and potentially uncovering underlying issues. It also avoids judgment or direct orders, fostering a therapeutic nurse-patient relationship. Explanation of why the other choices are incorrect: A: "Smoking is the reason you are here." - This response is blaming and may increase the patient's guilt or anxiety, hindering effective communication. B: "The doctor left orders for you not to smoke." - This response is authoritative and may lead to resistance or defensiveness from the patient, rather than addressing his concerns. D: "Smoking is OK right now, but after your surgery it is contraindicated." - This response is unclear and may send mixed messages to the patient, potentially leading to confusion or misunderstanding.

Correct Answer: A

Rationale: The correct answer is A: Charts legibly. This is accurate legally because clear and legible documentation is crucial for accurately conveying patient information, ensuring continuity of care, and meeting legal standards. Illegible handwriting can lead to errors in patient care and legal issues. Choice B is incorrect as labeling a patient as "belligerent" without evidence can be perceived as unprofessional and potentially harmful to the patient. Choice C is incorrect as writing an entry for another nurse can lead to inaccurate documentation and legal consequences. Choice D is incorrect because using correction fluid can raise suspicion of tampering with records and compromise the integrity of the documentation.

Correct Answer: D

Rationale: Correct Answer: D Rationale: - Giving a change-of-shift report to the oncoming nurse about the patient is an appropriate action that maintains confidentiality by only sharing necessary patient information with authorized healthcare professionals. - A: Writing the patient�s room number and date of birth on a paper for school is a breach of confidentiality as it exposes sensitive patient information to unauthorized individuals. - B: Printing/copying material from the patient�s health record for a graded care plan is also a breach of confidentiality as it involves sharing patient information without proper authorization. - C: Reviewing assigned patient�s record and another unassigned patient�s record is a violation of HIPAA as it involves accessing patient information that is not necessary for the nurse's duties, risking unauthorized disclosure.

Correct Answer: C

Rationale: Step 1: Malnourishment often leads to iron deficiency anemia, causing spoon-shaped nails (koilonychia). Step 2: Koilonychia is a classic sign of chronic malnutrition and iron deficiency. Step 3: Moist lips (A) and pink conjunctivae (B) are not specific to malnourishment. Step 4: Not easily plucked hair (D) is more related to hair health rather than malnutrition.