foundations of nursing test bank

Correct Answer: C

Rationale: Step 1: Malnourishment often leads to iron deficiency anemia, causing spoon-shaped nails (koilonychia). Step 2: Koilonychia is a classic sign of chronic malnutrition and iron deficiency. Step 3: Moist lips (A) and pink conjunctivae (B) are not specific to malnourishment. Step 4: Not easily plucked hair (D) is more related to hair health rather than malnutrition.

Correct Answer: B

Rationale: The correct answer is B because the nurse should prioritize the patient who has been receiving total parenteral nutrition (TPN) infusing with the same tubing for 26 hours. This patient needs to be seen first to monitor for any potential complications or issues related to TPN administration. Choice A can be ruled out because 50 hours is longer than 26 hours. Choices C and D involve enteral feeding, which is important but generally less critical than TPN. Additionally, choice D has a shorter duration than choice B. Therefore, choice B is the most time-sensitive and critical patient to assess first.

Correct Answer: A

Rationale: The correct answer is A: Teach the patient how to self-cath the pouch. In a continent urinary reservoir, patients need to catheterize the pouch several times a day. This is essential for emptying the urine from the pouch as the ileocecal valve creates a one-way valve. Teaching the patient how to self-catheterize ensures proper and timely drainage, preventing complications like urinary retention. Self-catheterization also empowers the patient to take an active role in managing their continence. Summary of other choices: B: Kegel exercises are ineffective for a patient with a continent urinary reservoir as they do not address the need for catheterization. C: Changing the collection pouch is not the primary action needed for a continent urinary reservoir. Catheterization is essential for drainage. D: The Valsalva technique is not appropriate for voiding in a continent urinary reservoir. Catheterization is the recommended method for emptying the pouch.

Correct Answer: C

Rationale: Step 1: After mastoid surgery, patients may experience pain and dizziness, hence addressing the safe use of analgesics and antivertiginous agents is crucial for symptom management. Step 2: Analgesics help in managing post-operative pain, while antivertiginous agents help control dizziness, reducing the risk of falls. Step 3: Educating the patient on safe use ensures proper pain and symptom management, preventing complications. Step 4: Other choices are incorrect as they do not directly address immediate post-operative care needs such as pain and dizziness management.

Correct Answer: D

Rationale: Correct Answer: D Rationale: - Giving a change-of-shift report to the oncoming nurse about the patient is an appropriate action that maintains confidentiality by only sharing necessary patient information with authorized healthcare professionals. - A: Writing the patient�s room number and date of birth on a paper for school is a breach of confidentiality as it exposes sensitive patient information to unauthorized individuals. - B: Printing/copying material from the patient�s health record for a graded care plan is also a breach of confidentiality as it involves sharing patient information without proper authorization. - C: Reviewing assigned patient�s record and another unassigned patient�s record is a violation of HIPAA as it involves accessing patient information that is not necessary for the nurse's duties, risking unauthorized disclosure.