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: 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 because encouraging the patient to verbalize concerns can help alleviate anxiety by allowing the patient to express emotions and fears. This intervention promotes emotional expression and provides an outlet for the patient to discuss their worries. This can lead to increased understanding and support. Incorrect answers: A: Administering antianxiety medications does not address the underlying cause of anxiety and may lead to dependency. B: Instructing the family on planning care does not directly address the patient's anxiety. D: Distracting the patient may provide temporary relief but does not address the root cause of anxiety related to lack of control over health circumstances.

Correct Answer: A

Rationale: The correct answer is A: Stop the infusion of magnesium. A magnesium level of 6 mg/dL is above the therapeutic range (4-7 mg/dL) for preeclamptic patients receiving magnesium sulfate. Continuing the infusion can lead to magnesium toxicity, causing respiratory depression, cardiac arrest, and neuromuscular blockade. Stopping the infusion is crucial to prevent further complications. Assessing the patient's respiratory rate (B) and deep tendon reflexes (C) are important, but stopping the infusion takes priority to prevent harm. Notifying the health care provider (D) is important but may delay immediate action to address the high magnesium level.

Correct Answer: B

Rationale: The correct answer is B: What do you call your problem? In the explanatory model, this question helps the nurse understand the patient's perspective and cultural beliefs about their illness. By asking how the patient labels their illness, the nurse gains insight into the patient's understanding of the illness, which can influence their treatment adherence and outcomes. The other options are incorrect because: A: How should your sickness be treated? - This question focuses on treatment preferences rather than understanding the patient's beliefs. C: How does this illness work inside your body? - This question is more aligned with the biomedical model, seeking physiological explanations rather than patient perspectives. D: What do you fear most about your sickness? - While important for assessing emotional aspects, this question does not directly address the patient's explanatory model.