Adult Health Nursing Test Banks

Correct Answer: B

Rationale: The correct action for the nurse to ensure proper insertion technique during a urinary catheterization is to use aseptic technique and sterile equipment. This is crucial in preventing infections and ensuring patient safety. Aseptic technique involves maintaining cleanliness and preventing the introduction of harmful microorganisms during invasive procedures like catheterization. Using sterile equipment helps minimize the risk of introducing bacteria into the urinary tract, which could lead to a urinary tract infection (UTI). Therefore, it is essential that the nurse follows strict infection control protocols and uses sterile equipment to maintain patient safety and well-being during the catheterization procedure.

Correct Answer: B

Rationale: Supplying the patient with paper tissues to use when touching doorknobs is the most appropriate response in this situation. This action acknowledges and respects the patient's anxiety while providing a practical solution to help her cope. Forcing her to touch doorknobs or discouraging her concerns would not address the underlying anxiety and may lead to increased distress. Encouraging her to scrub doorknobs with a strong antiseptic is not necessary and may exacerbate her anxiety. Explaining that her concerns are part of her illness may invalidate her feelings and is not a constructive way to address the situation. Supplying her with paper tissues allows her to feel more comfortable while still being able to navigate her daily activities.

Correct Answer: D

Rationale: When a client experiences cardiac arrest, their breathing may become insufficient, leading to inadequate elimination of carbon dioxide (CO2) from the body. With reduced CO2 elimination, the level of CO2 in the bloodstream increases, causing respiratory acidosis. This imbalance is characterized by a decrease in blood pH along with an increase in CO2 levels in the blood, resulting in an acidic environment. Respiratory acidosis is the most common imbalance seen in clients who have experienced cardiac arrest, as impaired gas exchange impacts the body's ability to maintain proper acid-base balance.

Correct Answer: D

Rationale: A delimitation in a research study refers to setting specific boundaries or restrictions on the scope of the study. In this scenario, Gloria's decision to include only nurses with a minimum of three years experience as psychiatric nurses is a delimitation because it sets a specific criterion or boundary for the selection of participants. This helps to focus the study on a particular group of individuals who possess the required experience, ensuring the research is targeted and relevant to the topic being investigated.

Correct Answer: A

Rationale: The patient with a history of COPD presenting with increased dyspnea, cough productive of purulent sputum, and coarse crackles on auscultation is most likely experiencing an acute exacerbation of COPD. Acute exacerbations in COPD are defined as sustained worsening of the patient's respiratory symptoms beyond normal day-to-day variations, leading to a change in medication. Common triggers for exacerbations include respiratory infections, air pollution, and non-compliance with medications.