Adult Health Med Surg Nursing Test Banks

Correct Answer: A

Rationale: When a baby is placed on phototherapy, especially for treating jaundice, it is crucial for the nurses to put sunglasses on the newborn to protect their eyes. Phototherapy involves exposing the baby's skin to certain types of light to help break down the bilirubin causing the jaundice. However, this light can be harmful to the baby's sensitive eyes, potentially leading to eye damage or other eye-related issues if not protected adequately. Therefore, placing sunglasses on the newborn is a necessary precaution to ensure the safety and well-being of the baby's eyes during the treatment.

Correct Answer: B

Rationale: The assessment of a patient who has ingested poison must include determining the poison ingested and the amount (I), the time from ingestion and the signs and symptoms (II), as well as the weight of the patient (III). These factors are essential in evaluating the severity of the poisoning and determining the appropriate treatment plan. However, the patient's immunization history (IV) is not directly relevant to the assessment of ingested poison and thus is not essential in this context.

Correct Answer: D

Rationale: Taking off the room lights and drawing the window shades would provide a calm and soothing environment for the five-year-old patient admitted due to pneumonia with symptoms of cough, respiratory distress, anxiety, and dehydration. By creating a dim and quiet atmosphere, it can help reduce the child's anxiety levels, promote rest and relaxation, and potentially aid in the management of distress caused by pneumonia. Providing a quiet and dark environment can also support the child's comfort and recovery process during the hospital stay.

Correct Answer: B

Rationale: Normal saline is the preferred solution for wound irrigation because it is isotonic and will not damage healthy tissue or delay wound healing. It helps to remove debris and pathogens from the wound, promoting a clean environment for healing. Sterile water can be used if normal saline is not available, but it may cause cellular damage if used in large volumes. Hydrogen peroxide and Betadine solution are not recommended for wound irrigation as they can be cytotoxic to the tissues and interfere with the wound healing process. It's important for the nurse to use evidence-based practice and follow recommended guidelines to promote optimal wound healing outcomes.

Correct Answer: C

Rationale: Naloxone, also known by the brand name Narcan, is used to reverse the effects of opioid overdose. Opioids can cause respiratory depression, sedation, and other signs of toxicity. Administering naloxone can quickly reverse these effects, restoring the patient's breathing and consciousness. This makes it the appropriate choice for reversing all signs of toxicity related to opioids. Digibind (Digoxin) is used to reverse toxicity from digoxin specifically. Atropine sulfate is used for bradycardia. Diazepam (Valium) is a benzodiazepine used for anxiety, seizures, and muscle relaxation, not for reversing toxicity.