Foundations and Adult Health Nursing Test Bank

Correct Answer: C

Rationale: In the emergency department setting, the initial diagnostic test typically performed for a patient suspected of having a stroke is a noncontrast computed tomography (CT) scan of the head. This imaging study is crucial in evaluating and diagnosing stroke because it can quickly identify whether the person is having a hemorrhagic stroke (bleeding in the brain) or an ischemic stroke (blood clot blocking a blood vessel). The results of the CT scan help guide immediate treatment decisions, such as administering clot-busting medications for ischemic strokes or preparing for surgical interventions for hemorrhagic strokes. Carotid ultrasound studies and transcranial Doppler flow studies may be performed after the initial CT scan to further assess the extent of damage and the underlying cause of the stroke. The 12-lead electrocardiogram is useful in assessing the heart's electrical activity but is not the primary test for diagnosing stroke.

Correct Answer: A

Rationale: Nurse Adalynn explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage is an increasing pulse and decreasing blood pressure. Hypovolemia is a condition where there is a decreased volume of circulating blood in the body, often characterized by fluid loss such as through bleeding. As blood volume decreases, the heart rate increases in an attempt to maintain adequate perfusion to organs and tissues. This results in an elevated pulse rate. Additionally, as the blood volume decreases, the blood pressure may drop due to the reduced amount of blood being pumped around the body. Therefore, monitoring for an increasing pulse and decreasing blood pressure is crucial in detecting hypovolemia early, allowing for prompt intervention to prevent further complications.

Correct Answer: C

Rationale: Cleaning the inner cannula daily helps prevent the accumulation of secretions and debris, which can lead to blockages and infections. It is an essential aspect of tracheostomy care to maintain the patency of the airway and prevent complications. Caregivers should be taught how to safely remove, clean, and reinsert the inner cannula as part of routine tracheostomy care.

Correct Answer: C

Rationale: If the nurse notices that the patient's arms are not adequately padded while positioning for surgery, the nurse should immediately take action to prevent pressure injuries. Applying soft padding to the patient's arms will help distribute the pressure more evenly, reducing the risk of skin breakdown and potential harm to the patient during the surgical procedure. It is essential to prioritize the patient's safety and comfort in such situations. Simply proceeding with the positioning as planned could lead to complications, so addressing the inadequate padding promptly is the appropriate course of action.

Correct Answer: A

Rationale: The primary purpose of splinting a fractured extremity in the pre-hospital setting is to immobilize the injured area in order to prevent further injury. By stabilizing the fracture, splinting helps to reduce movement, which can alleviate pain, prevent additional damage to surrounding tissues, and minimize the risk of causing more harm during transport or while providing care. Splinting also helps to maintain proper alignment of the bones, which is crucial for the healing process and long-term function of the injured limb.