foundations of nursing test bank

Correct Answer: A

Rationale: The correct answer is A: Assessing for mouth droop and decreased lateral eye gaze. After a radical mastoidectomy, the nurse should prioritize assessing for signs of facial nerve damage, such as mouth droop and decreased lateral eye gaze, which can indicate injury to the facial nerve during surgery. This is crucial as immediate intervention may be needed to prevent long-term complications. Choices B, C, and D are incorrect: B: Assessing for increased middle ear pressure and perforated ear drum is not the priority postoperative care for a radical mastoidectomy patient. C: Assessing for gradual onset of conductive hearing loss and nystagmus is not the priority as these are not immediate concerns postoperatively. D: Assessing for scar tissue and cerumen obstructing the auditory canal is not the priority as these are not immediate postoperative complications that require urgent attention.

Correct Answer: C

Rationale: The correct answer is C because it includes all necessary components for a complete and accurate chart entry. The nurse documents the date and time of the order, the medication prescribed (Morphine, 2 mg, IV every 4 hours), the indication for use (incisional pain), the intended recipient (Dr. Day), the nurse's name (J. Winds), and confirmation of the read-back procedure. This entry ensures clarity, accountability, and proper communication among healthcare team members. Choice A is incorrect because it misses the recipient of the order (Dr. Day) and only includes the nurse's name in the read-back. Choice B is incorrect because it lacks the recipient of the order and the confirmation of the read-back procedure with the primary care provider. Choice D is incorrect because it does not specify the primary care provider who gave the order and misses the read-back confirmation with the provider.

Correct Answer: A

Rationale: The correct answer is A: Utilize a pressure-reducing mattress. This intervention is crucial for preventing pressure ulcers in patients at risk for impaired skin integrity, such as those with HIV. By redistributing pressure, a pressure-reducing mattress helps to alleviate pressure on vulnerable areas, reducing the risk of skin breakdown. Limiting physical activity (B) can lead to muscle atrophy and worsen skin integrity. Applying antibiotic ointment (C) may not address the root cause of skin breakdown. Avoiding synthetic fabrics (D) may be helpful in some cases, but it is not as effective as using a pressure-reducing mattress.

Correct Answer: B

Rationale: The correct answer is B: Healers. In the ETHNIC mnemonic, "H" stands for Healers, where the nurse assesses the individual's traditional healers, healthcare practices, and preferences for seeking healthcare. This is important in understanding the individual's cultural beliefs and practices related to health and treatment. Assessing "Health" (A) may be important, but it does not specifically address traditional healers. "History" (C) focuses on the individual's cultural background rather than healthcare practices. "Homeland" (D) pertains to the individual's place of origin, which is not directly related to healthcare communication.

Correct Answer: A

Rationale: Step 1: Finasteride is a medication that works by decreasing glandular cellular activity and reducing prostate size. Step 2: Dietary supplements can interact with finasteride, potentially affecting its effectiveness or causing adverse effects. Step 3: Reporting the planned use of dietary supplements to the physician ensures proper monitoring and adjustment of the treatment plan. Step 4: This communication promotes patient safety and optimal therapeutic outcomes. Therefore, choice A is correct as it emphasizes the importance of informing the physician about dietary supplement use to ensure the efficacy and safety of finasteride. Choices B, C, and D are incorrect as they do not directly relate to the mechanism of action or specific considerations of finasteride therapy.