test bank foundations of nursing

Correct Answer: A

Rationale: The correct answer is A because a protein level of 2 mg/100 mL in urine indicates proteinuria, which can be a sign of kidney dysfunction or other underlying health issues. The nurse should follow up to assess further for possible kidney disease or other conditions. Choice B is not a cause for concern as a urine output of 80 mL/hr is within the normal range. Choice C indicates concentrated urine, which may be due to dehydration but does not necessarily require immediate follow-up. Choice D is within the normal range for urine pH and does not typically warrant immediate follow-up.

Correct Answer: B

Rationale: The correct answer is B. By asking the patient to demonstrate the instillation of medications, the nurse can directly assess the patient's ability to self-administer the medications safely and effectively. This method allows for a practical demonstration of skills, which is more reliable than relying solely on verbal descriptions or past experiences. Choices A, C, and D are incorrect because assessing for previous inability, describing the method, or evaluating functional status may not directly demonstrate the patient's competency in self-administering ocular medications.

Correct Answer: C

Rationale: The correct answer is C because putting on a second pair of gloves over soiled gloves during a procedure violates standard precautions by increasing contamination risk. Here's the rationale: 1. Standard precautions require removing soiled gloves before putting on new ones to prevent cross-contamination. 2. Wearing multiple gloves increases the risk of tearing and exposure to pathogens. 3. This behavior shows a lack of understanding of proper infection control practices. Summary of other choices: A: Wearing face protection, gloves, and a gown when irrigating a wound is a correct practice. B: Washing hands with waterless antiseptic after removing soiled gloves is correct. D: Placing a used needle and syringe in a puncture-resistant container without capping the needle is incorrect, but not as severe as choice C.

Correct Answer: A

Rationale: The correct answer is A: 10-mL Luer-Lok syringe. The nurse should use this syringe to obtain a gastric aspirate for pH testing because it allows for accurate measurement of the aspirate volume. Asepto syringe (B) is not suitable for this purpose as it is not designed for accurate measurement. Sterile gloves (C) and double gloves (D) are not equipment used specifically for obtaining gastric aspirate for pH testing. Sterile gloves are used for infection control, and double gloves are used for additional protection during procedures.

Correct Answer: D

Rationale: Correct Answer: D - Removing all of the patient�s metallic jewelry. Rationale: 1. Safety: Metallic objects can be attracted by the MRI magnet, causing harm to the patient and disrupting the imaging process. 2. Artifact Prevention: Metallic objects can produce artifacts on the MRI images, affecting the diagnostic quality. 3. Patient Comfort: Removing jewelry ensures the patient's comfort during the scan, avoiding discomfort or injury. Summary of Incorrect Choices: A: Not eating or drinking before an MRI is important, but it is not the most crucial action compared to patient safety and image quality. B: Colon cleansing may be necessary for certain types of MRI scans, but it is not universally required and is not the most important action. C: Pain medication may be important for patient comfort, but it is not essential for the actual MRI procedure and does not impact safety or image quality.