Foundations and Adult Health Nursing Test Bank

Correct Answer: A

Rationale: In a patient with suspected pulmonary TB, the most appropriate diagnostic test for confirming the diagnosis is the sputum acid-fast bacilli (AFB) smear and culture. This test involves examining sputum samples under the microscope for the presence of acid-fast bacilli, which are characteristic of Mycobacterium tuberculosis, the bacteria that causes TB. Additionally, culturing the sputum allows for the bacteria to grow in a controlled environment, further confirming the diagnosis. In the given scenario, the patient's symptoms (cough, weight loss, night sweats, hemoptysis), along with chest X-ray findings of upper lobe infiltrates and cavitation, are highly suggestive of pulmonary TB. Therefore, performing a sputum AFB smear and culture is crucial for definitive diagnosis and initiation of appropriate treatment. The other options (Tuberculin skin test, Interferon

Correct Answer: C

Rationale: When a patient expresses concern about a medication looking different from what they had taken before, it is crucial for the nurse to verify the original prescription to ensure that the correct medication is being administered. Checking the original medication prescription will help the nurse confirm if there have been any changes or errors in the medication orders. This step is essential for patient safety and to prevent any potential medication errors. It is important to prioritize patient safety and well-being in such situations, and verifying the prescription is the appropriate action to take in this case.

Correct Answer: B

Rationale: When a patient is in skin traction, the constant pressure and rubbing against the skin from the traction device can lead to skin breakdown. Therefore, assessing for signs of skin breakdown, such as redness, irritation, or pressure injuries, is crucial to prevent complications and ensure the patient's comfort and safety. Prompt identification and intervention for any skin issues can prevent further damage and promote healing, making this the priority intervention for quality nursing care in skin traction. While monitoring for signs of infection, urinary incontinence, and bowel sounds are important, skin breakdown poses a more immediate threat to the patient's well-being in this scenario.

Correct Answer: A

Rationale: Administering systemic analgesia, such as pain medications or anesthesia, before the wound debridement procedure is the most effective way to minimize patient discomfort. These medications will help manage and reduce the pain experienced by the patient during the procedure, making it more tolerable for them. Topical anesthetic cream may provide some localized relief but may not be sufficient for significant pain management during a wound debridement procedure. Using sharp debridement techniques or performing the procedure quickly may help reduce manipulation or duration, respectively, but these actions alone may not adequately address the patient's pain and discomfort. Administering systemic analgesia ensures that the patient's overall pain is managed, promoting a more comfortable and successful wound debridement procedure.

Correct Answer: B

Rationale: Type I IgE-mediated immediate hypersensitivity reactions, such as anaphylaxis, are promptly managed with epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it helps counteract the severe symptoms by relaxing the muscles in the airways, constricting blood vessels, and decreasing swelling. It acts quickly to reverse the potentially life-threatening effects of the allergic reaction and is crucial in managing anaphylaxis effectively. Other medications like antihistamines (e.g., diphenhydramine) and corticosteroids may be used as adjuncts, but epinephrine remains the primary treatment for immediate hypersensitivity reactions.