Foundations and Adult Health Nursing Test Bank

Correct Answer: A

Rationale: Nurse Adalynn explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage is an increasing pulse and decreasing blood pressure. Hypovolemia is a condition where there is a decreased volume of circulating blood in the body, often characterized by fluid loss such as through bleeding. As blood volume decreases, the heart rate increases in an attempt to maintain adequate perfusion to organs and tissues. This results in an elevated pulse rate. Additionally, as the blood volume decreases, the blood pressure may drop due to the reduced amount of blood being pumped around the body. Therefore, monitoring for an increasing pulse and decreasing blood pressure is crucial in detecting hypovolemia early, allowing for prompt intervention to prevent further complications.

Correct Answer: B

Rationale: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked recessive disorder that leads to hemolytic anemia in response to oxidative stress. The patient's presentation of fatigue, weakness, and jaundice along with laboratory findings of hemolytic anemia (evidenced by schistocytes), elevated LDH, and decreased haptoglobin are all characteristic of G6PD deficiency. The oxidative stress causes red blood cell destruction, resulting in the release of LDH and bilirubin, leading to jaundice. Decreased haptoglobin is seen due to its consumption in binding free hemoglobin released from the lysed red blood cells. Additionally, the presence of schistocytes on a peripheral blood smear is indicative of red blood cell fragmentation, a common finding in hemolytic anemias including G6PD deficiency

Correct Answer: B

Rationale: The patient's presentation with renal failure, confusion, seizures, asterixis, and a sweet odor to the breath, along with laboratory findings of severe metabolic acidosis, hyperkalemia, and elevated BUN and creatinine levels, is consistent with uremic encephalopathy. Uremic encephalopathy is a neurological complication of acute or chronic renal failure resulting from the buildup of uremic toxins in the blood, leading to various neurological symptoms such as confusion and seizures. The sweet odor to the breath can be attributed to the presence of urea, a waste product that accumulates in renal failure. Other metabolic abnormalities like hyperkalemia and severe metabolic acidosis are also common in renal failure. It is crucial to promptly recognize and manage uremic encephalopathy to prevent further neurological complications.

Correct Answer: C

Rationale: Monitoring cardiac enzymes would be most helpful to Nurse Victor to confirm the underlying cause of cardiogenic shock. Cardiac enzymes are specific markers in the blood that indicate damage to the heart muscle, such as troponin and creatine kinase-MB (CK-MB). When a patient experiences cardiogenic shock, there is usually damage to the heart muscle which leads to the release of these enzymes into the bloodstream. Monitoring cardiac enzymes can help confirm if the cause of cardiogenic shock is related to myocardial infarction or another cardiac issue. This information is crucial for determining the appropriate treatment and management plan for the patient. Monitoring pulmonary artery pressure, mean arterial pressure, and central venous pressure may provide important hemodynamic information but may not directly confirm the underlying cause of cardiogenic shock.

Correct Answer: C

Rationale: Nurse Ace submitting a report to the physician about committing an error in medication demonstrates accountability. Accountability in healthcare refers to the responsibility of individuals to answer for their actions, decisions, and behaviors in the professional setting. By taking ownership of the mistake and informing the physician, Nurse Ace is showing accountability for her actions, ensuring that patient safety remains a priority. Compliance with reporting errors is essential for quality improvement and patient safety in healthcare settings.