Adult Health Nursing Test Bank

Correct Answer: A

Rationale: The correct answer is A because obtaining the client's own consent is the first step in ensuring the client's autonomy and right to make decisions about their own care. This is in line with ethical principles of informed consent. Choices B, C, and D are incorrect because consent should come directly from the client, not from a spouse, family member, or social worker. Choice B violates the principle of individual autonomy, choice C is not the priority before admission, and choice D is not the appropriate person to provide consent.

Correct Answer: C

Rationale: The correct answer is C: Secures clean ties before removing soiled ones. This is the priority action because securing clean ties prevents accidental dislodgement of the tracheostomy tube, ensuring the patient's airway remains patent. Cutting the dressing (A) or cleaning the incisions (B) can be important but not as critical as securing the tube. Using clean technique (D) is essential but not the priority in this situation.

Correct Answer: B

Rationale: The correct answer is B: Initiate non-invasive positive pressure ventilation (NIPPV) for respiratory support. In acute exacerbations of COPD, NIPPV helps improve ventilation and oxygenation, reducing the work of breathing and preventing the need for intubation. This intervention is a priority as it can rapidly stabilize the patient's respiratory status. A: Administering bronchodilator medications is important in COPD management, but in severe exacerbations, NIPPV takes precedence. C: Arterial blood gas analysis is important for assessing oxygenation and ventilation status, but it does not directly address the acute respiratory distress. D: Chest physiotherapy can help with airway clearance in COPD, but in acute exacerbations, respiratory support with NIPPV is more urgent.

Correct Answer: C

Rationale: The correct answer is C because encouraging the patient to ask questions and express concerns promotes patient empowerment and active participation in self-care. This approach fosters communication, understanding, and collaboration between the nurse and patient, leading to better medication adherence. Choice A is incorrect as it lacks patient involvement. Choice B is helpful but does not necessarily empower the patient. Choice D is directive and does not encourage active participation or empowerment.

Correct Answer: B

Rationale: The correct answer is B: Bronchoscopy. This procedure involves inserting a thin, flexible tube with a camera through the mouth or nose to examine the tracheobronchial tree. It allows direct visualization of the airways, collection of tissue samples for biopsy, and detection of abnormalities like tumors. A: CT scan provides detailed images of the lungs but does not allow for direct tissue sampling. C: Sputum cytology involves examining sputum for cancer cells but may not provide accurate results. D: PET scan is used to detect metabolic activity in tissues, including tumors, but does not provide detailed visualization of the airways or allow for biopsies.