Adult Health Med Surg Nursing Test Banks

Correct Answer: C

Rationale: Tetanus toxoid provides long-lasting active immunity. When a person is vaccinated with tetanus toxoid, their immune system is stimulated to produce antibodies against the tetanus toxin. These antibodies provide protection against tetanus infection by recognizing and neutralizing the toxin if the person is exposed to the bacteria that causes tetanus in the future. This active immune response can last for many years, providing ongoing protection against tetanus. However, booster doses are recommended every 10 years to maintain adequate levels of protection.

Correct Answer: C

Rationale: An abstract is a concise summary of a research study that provides an overview of the purpose, methods, results, and conclusions of the research. It is usually the first section of a research report or article and serves to give the reader a quick understanding of the study without having to read the full document. In this case, Nurse Sandy has completed the study and is preparing to submit a written brief summary to the Research department, which is typically in the form of an abstract. It highlights the key points of the study, allowing others to quickly grasp the main findings and implications.

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: 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: A

Rationale: The first responsibility of a nurse when a patient falls is to assess the patient's injury. Assessing the patient's injury immediately allows the nurse to determine the severity of the fall and provide appropriate care and interventions. It is important to assess for any signs of injury, such as pain, swelling, bruising, or altered mobility, and to address any immediate medical needs. Once the patient's injury has been assessed, the nurse can then proceed to report the incident to the head nurse, write an incident report, and notify the physician if necessary.