Adult Health Med Surg Nursing Test Banks

Correct Answer: B

Rationale: The best prevention management of contact latex allergy is to avoid latex products entirely. Latex allergies can range from mild skin irritation to severe reactions such as anaphylaxis. This means that even applying lotion before using latex gloves may not be sufficient to prevent an allergic reaction in individuals who are sensitized to latex. It is important for individuals with latex allergy to completely avoid exposure to latex products, including rubberized goods, to prevent triggering an allergic response. Resigning from the job is not a practical solution and should not be necessary if proper precautions are taken to avoid latex exposure.

Correct Answer: C

Rationale: The patient's presentation of swelling of the ankles, dyspnea on exertion, and orthopnea is highly suggestive of heart failure. The echocardiogram findings of decreased left ventricular ejection fraction and dilated left ventricle are characteristic of heart failure with reduced ejection fraction (HFrEF), also known as systolic heart failure. In this condition, the heart's ability to pump blood effectively is compromised, leading to symptoms of congestion and decreased cardiac output. The decreased ejection fraction indicates that the heart is not able to efficiently pump out blood with each contraction. Dilatation of the left ventricle is a compensatory mechanism in response to increased volume overload.

Correct Answer: B

Rationale: The nurse's best action in this situation would be to administer the ordered antibiotic trimethoprim (Trimpex). A urinary tract infection (UTI) requires antibiotic treatment to eliminate the bacterial infection causing the symptoms. Phenazopyridine hydrochloride is a urinary tract analgesic that can help relieve urinary pain but does not treat the infection itself. Bethanechol is a cholinergic medication used to treat urinary retention, not a UTI. Acetaminophen and a warm bath may help with some discomfort but do not address the underlying infection causing the urinary pain. Therefore, administering the prescribed antibiotic would be the most appropriate action to target the source of the patient's symptoms.

Correct Answer: B

Rationale: The nurse should prioritize cleansing the insertion site with an alcohol-based antiseptic solution to maintain procedural asepsis during a peripherally inserted central catheter (PICC) insertion. Proper skin preparation is essential in reducing the risk of introducing pathogens into the patient's bloodstream during the insertion process. Alcohol-based antiseptic solutions are effective in reducing the number of microorganisms on the skin surface. Wearing sterile gloves and following other sterile techniques are also crucial, but preparing the insertion site with the antiseptic solution is the initial step in maintaining asepsis during the procedure.

Correct Answer: B

Rationale: A prolapsed umbilical cord is a medical emergency during labor because it can cause compression of the umbilical cord, leading to decreased oxygen supply to the fetus. The priority nursing action in this situation is to prepare for an immediate cesarean section. This is necessary to quickly deliver the baby and relieve pressure on the cord, preventing potential fetal distress or death. Elevating the mother's hips may help reduce pressure on the cord temporarily, but it is not the definitive treatment for a prolapsed cord. Administering intravenous fluids rapidly may be necessary, but it is not the priority intervention when the fetus is at risk due to a prolapsed cord. Performing a vaginal examination to assess cervical dilation is contraindicated in the presence of a prolapsed umbilical cord as it can further compress the cord and worsen the situation.