Foundations and Adult Health Nursing Test Bank

Correct Answer: B

Rationale: Validity refers to the extent to which a test accurately measures what it is intended to measure. In the context of screening tests for diseases, validity is crucial in assessing whether the test can correctly distinguish between individuals who have the disease (true positives) and those who do not have the disease (true negatives). This includes the ability to minimize false positives (incorrectly identifying someone as having the disease) and false negatives (incorrectly identifying someone as not having the disease). Therefore, when assessing the ability of a screening test to distinguish correctly between persons with and without a disease, we are essentially evaluating its validity.

Correct Answer: A

Rationale: The nurse should prioritize using sterile technique during the tracheostomy tube change to ensure patient safety. Tracheostomy procedures involve a direct entry into the airway, making it crucial to prevent infection and reduce the risk of complications. Sterile technique, including proper hand hygiene, wearing sterile gloves, and using sterile equipment, helps minimize the introduction of pathogens into the patient's airway, reducing the risk of infection. By maintaining a sterile field, the nurse can protect the patient from potential harm and promote a successful outcome of the tracheostomy tube change.

Correct Answer: D

Rationale: Advocacy is the ethical principle that the nurse is responsible for providing all patients with caring attention and information, despite the reaction of the patient. Advocacy involves supporting and speaking up for the patient's best interests, ensuring they receive the care and information they need to make informed decisions about their health and well-being. Providing caring attention and information is essential in advocating for the patient's autonomy and well-being, even if the patient may not initially appreciate or react positively to these efforts.

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: A

Rationale: Of the options provided, documenting objective, observable findings such as large bruises on the thigh upon assessment is the most defensible entry in court. This type of entry is based on the nurse's direct observation and assessment of the patient's physical condition, which can be corroborated by other healthcare providers or evidence. It provides clear, factual information without making assumptions or subjective judgments. In court, this type of documentation can help support the nurse's credibility and reliability as a witness.