test bank foundations of nursing

Correct Answer: C

Rationale: The correct answer is C: Lets explore other options, because laxatives can have side effects and create dependency. The rationale for this is that while laxatives provide temporary relief for constipation, using them long-term can lead to dependency, electrolyte imbalances, and other side effects. The nurse should address the root cause of constipation and explore alternative strategies such as dietary changes, increased fluid intake, exercise, and bowel training. Choices A and B focus on supportive measures rather than addressing the issue of potential dependency on laxatives. Choice D suggests herbal remedies without considering the individual's specific condition and medical history.

Correct Answer: B

Rationale: The correct answer is B: At least once every 2 years. Glaucoma has a familial tendency, meaning it can run in families. Regular eye exams are crucial for early detection and treatment. Having family members undergo clinical examinations every 2 years allows for timely identification of any potential signs of glaucoma. Monthly exams (A) would be too frequent and unnecessary. Exams every 5 years (C) or 10 years (D) are too infrequent and may miss early signs of the disease. Regular biennial exams strike a balance between early detection and practicality.

Correct Answer: C

Rationale: The correct answer is C because putting on a second pair of gloves over soiled gloves during a procedure violates standard precautions by increasing contamination risk. Here's the rationale: 1. Standard precautions require removing soiled gloves before putting on new ones to prevent cross-contamination. 2. Wearing multiple gloves increases the risk of tearing and exposure to pathogens. 3. This behavior shows a lack of understanding of proper infection control practices. Summary of other choices: A: Wearing face protection, gloves, and a gown when irrigating a wound is a correct practice. B: Washing hands with waterless antiseptic after removing soiled gloves is correct. D: Placing a used needle and syringe in a puncture-resistant container without capping the needle is incorrect, but not as severe as choice C.

Correct Answer: B

Rationale: The correct answer is B: Compensating for vision loss for the next several weeks. This is the priority subject for discharge education because vision loss is a common outcome post vitreoretinal procedure. The patient needs to understand how to adapt to this temporary impairment, such as using assistive devices and modifying their environment. A: Risk factors for postoperative CMV is not the priority as it is not a common concern in this situation. C: Non-pharmacologic pain management is important but not the priority compared to vision loss. D: Signs and symptoms of increased intraocular pressure are important but not as crucial as managing vision loss.

Correct Answer: B

Rationale: The correct answer is B because Rh incompatibility occurs when an Rh-negative mother carries an Rh-positive fetus. If fetal blood enters the mother's circulation during pregnancy or childbirth, the mother's immune system can produce antibodies against Rh-positive red blood cells, leading to potential harm to future pregnancies. Choices A, C, and D are incorrect because Rh incompatibility does not occur when the fetus is Rh-negative, the father is Rh-positive, or both the father and fetus are Rh-negative.