test bank foundations of nursing

Correct Answer: B

Rationale: The correct answer is B: Importance of personal hygiene. Maintaining good personal hygiene is crucial for patients with HIV to prevent infections. This includes regular handwashing, oral care, and bathing. By emphasizing personal hygiene, the nurse can help the patient reduce the risk of opportunistic infections. Prophylactic antibiotics (choice A) are important but should be prescribed by the healthcare provider. Signs and symptoms of wasting syndrome (choice C) are significant, but focusing on prevention through hygiene is more practical. Adjusting antiretroviral dosages (choice D) is the responsibility of the healthcare provider, not the patient.

Correct Answer: C

Rationale: The correct answer is C: Normal deep tendon reflexes. This indicates a therapeutic level of magnesium sulfate as it shows that the medication is effectively preventing hyperreflexia, a common sign of magnesium toxicity. Drowsiness (choice A) can indicate toxicity. Urinary output of 20 mL/hour (choice B) is not specific to magnesium sulfate levels. Respiratory rate of 10 to 12 breaths per minute (choice D) is indicative of respiratory depression, a sign of magnesium toxicity. Thus, choice C is the best assessment to indicate a therapeutic level of medication in a patient with preeclampsia taking magnesium sulfate.

Correct Answer: C

Rationale: The correct answer is C: Monitor the patient for fever, rash, and difficulty breathing. The rationale is as follows: 1. Renal calculus obstruction can lead to complications such as infection, so monitoring for fever is crucial. 2. Rash can indicate an allergic reaction to the contrast dye used in the procedure. 3. Difficulty breathing may signal a severe reaction or complications. Summary: A: Turning the patient on the right side does not directly address the urgent need to monitor for potential complications. B: While fluid intake is important, it is not the immediate priority when the patient is at risk of developing complications. D: Administering narcotic medications may be necessary for pain relief but does not address the potential emergent issues related to the obstruction.

Correct Answer: C

Rationale: The correct answer is C: anticonvulsant. Magnesium sulfate is used in the treatment of preeclampsia to prevent seizures, making it an anticonvulsant. It works by reducing neuromuscular excitability and stabilizing nerve cell membranes. Choice A (diuretic) is incorrect because magnesium sulfate does not primarily promote diuresis. Choice B (tocolytic) is incorrect as it does not inhibit uterine contractions. Choice D (antihypertensive) is incorrect because although magnesium sulfate can help lower blood pressure in preeclampsia, its primary indication in this case is for seizure prophylaxis.

Correct Answer: C

Rationale: The correct answer is C: Epistaxis (nose bleed). Thrombocytopenia is a condition characterized by a low platelet count, leading to impaired blood clotting and an increased risk of bleeding. Epistaxis is a common symptom of thrombocytopenia due to the lack of platelets to aid in clot formation. Assessing for epistaxis in patients receiving carmustine is crucial to monitor and manage potential bleeding complications. Choices A, B, and D are incorrect as they are not directly associated with thrombocytopenia.