Foundations and Adult Health Nursing Test Bank

Correct Answer: A

Rationale: In a patient with acute myocardial infarction (MI) complicated by cardiogenic shock, the primary intervention to manage shock is emergent percutaneous coronary intervention (PCI). PCI is a procedure performed to restore blood flow in an occluded coronary artery that is causing the MI. By opening up the blocked artery and restoring blood flow to the heart muscle, PCI can help reduce myocardial damage, improve cardiac function, and stabilize the patient's condition. Prompt reperfusion via PCI is crucial in the setting of cardiogenic shock to improve survival outcomes and reduce the risk of further complications. Administering inotropic medications, initiating therapeutic hypothermia, or recommending anticoagulant therapy may be components of management in specific cases but are not the primary intervention for managing shock in a patient with acute MI and cardiogenic shock.

Correct Answer: A

Rationale: The nurse should prioritize using sterile technique during the tracheostomy tube change to ensure patient safety. Tracheostomy procedures involve a direct entry into the airway, making it crucial to prevent infection and reduce the risk of complications. Sterile technique, including proper hand hygiene, wearing sterile gloves, and using sterile equipment, helps minimize the introduction of pathogens into the patient's airway, reducing the risk of infection. By maintaining a sterile field, the nurse can protect the patient from potential harm and promote a successful outcome of the tracheostomy tube change.

Correct Answer: A

Rationale: The nurse in the practice of her profession is guided by a code of ethics, which outlines the moral duties and professional responsibilities of nurses. The code of ethics provides a framework for ethical decision-making and sets standards for professional behavior within the nursing profession. Nurses are expected to adhere to the principles of the code of ethics in order to promote the well-being and safety of their patients, maintain professional integrity, and uphold the values of nursing practice.

Correct Answer: A

Rationale: The first standard step in oxygen therapy that the nurse should do is to assess the client's condition. Before initiating any oxygen treatment, it is essential to assess the client's respiratory status, oxygen saturation levels, vital signs, and overall condition. This initial assessment helps the nurse to determine the appropriate course of oxygen therapy based on the client's individual needs and current health status. Assessing the client's condition first ensures that the oxygen therapy provided is safe and effective for the specific needs of the client.

Correct Answer: A

Rationale: Endometriosis is a condition characterized by the abnormal growth of endometrial tissue outside the uterus. One common symptom of endometriosis is excessive menstrual bleeding, known as menorrhagia. This excessive bleeding is due to the presence of endometrial tissue in abnormal locations, leading to inflammation, scarring, and blood accumulation. In severe cases, endometriosis can lead to the formation of adhesions, cysts, and scar tissue, causing significant pain and fertility issues for affected individuals. Endometrial hyperplasia, leiomyomas (uterine fibroids), and adenomyosis are other gynecological conditions, but they do not involve the abnormal proliferation of endometrial tissue outside the uterus like endometriosis does.