test bank foundations of nursing

Correct Answer: A

Rationale: The correct answer is A. Postoperative day 6 following tympanoplasty and mastoidectomy is still within the early phase of recovery, where occasional sharp, shooting pains in the affected ear can be expected due to the healing process. Here's a step-by-step rationale: 1. Timing: It is only day 6 post-surgery, so it is normal to experience some pain as part of the healing process. 2. Nature of pain: Sharp, shooting pains are common post-surgery due to tissue healing and nerve regeneration. 3. Lack of other symptoms: The patient did not report any other concerning symptoms like fever or discharge, which would be more indicative of an infection. 4. Unlikely complications: Spontaneous rupture of the tympanic membrane or unsuccessful surgery would typically present with more severe and consistent symptoms. Summary: - B: Unlikely as there are no other signs of infection. - C: Unlikely as the pain is described as occasional and sharp. - D:

Correct Answer: B

Rationale: The correct answer is B: Administration of methotrexate. This is the priority intervention for an intact tubal pregnancy to prevent further growth and potential rupture of the fallopian tube. Methotrexate is a medication used to stop the growth of the pregnancy tissue. Assessment of pain level (A) is important but not the priority as immediate intervention to address the ectopic pregnancy is crucial. Administration of Rh immune globulin (C) is not the priority in this situation, as it is typically given after a miscarriage or abortion to prevent Rh sensitization. Explanation of common side effects (D) is important for patient education, but it is not the immediate priority when dealing with an ectopic pregnancy.

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: C

Rationale: Rationale: 1. Erythema of nipple/areola in one breast can be a sign of Paget's disease, a rare form of breast cancer. 2. Paget's disease may also present with itching, tingling, or a burning sensation in the affected area. 3. Referring the patient promptly is crucial for early detection and appropriate management. 4. Peau d'orange (A) is a sign of advanced breast cancer, not typically presenting with erythema alone. 5. Nipple inversion (B) may be benign or related to other conditions, not typically presenting with erythema. 6. Acute mastitis (D) presents with breast pain, warmth, swelling, and fever, but not typically with isolated erythema of the nipple/areola.

Correct Answer: C

Rationale: The correct answer is C. Computer competency does not equate to informatics competency. Informatics involves more than just basic computer skills; it encompasses the ability to use technology to manage and analyze data for improved healthcare outcomes. A: This is a correct statement about informatics proficiency. B: This is also a correct statement about the skills needed for informatics. D: This is a true statement about nursing informatics being a recognized specialty, but it does not indicate a need for follow-up. In summary, choice C is incorrect as it oversimplifies the concept of informatics, while choices A, B, and D provide accurate information related to informatics.