test bank foundations of nursing

Correct Answer: C

Rationale: The correct answer is C: Work with the team to negotiate informed consent. In this scenario, the nurse should prioritize respecting the patient's cultural beliefs while also ensuring the patient's autonomy and right to make decisions about his own healthcare. By working with the healthcare team to negotiate informed consent, the nurse can involve both the patient and his eldest son in the decision-making process, ensuring that the patient's preferences are respected while also upholding ethical principles of patient autonomy and beneficence. This approach promotes collaboration and respect for cultural values while still safeguarding the patient's rights. Choice A is incorrect because it does not involve the patient in the decision-making process and could undermine his autonomy. Choice B is incorrect as it disregards the patient's cultural beliefs and preferences. Choice D is incorrect as it may violate the patient's right to information and involvement in his own care.

Correct Answer: C

Rationale: The correct answer is C: Normal deep tendon reflexes. This indicates a therapeutic level of magnesium sulfate as it shows that the medication is effectively preventing hyperreflexia, a common sign of magnesium toxicity. Drowsiness (choice A) can indicate toxicity. Urinary output of 20 mL/hour (choice B) is not specific to magnesium sulfate levels. Respiratory rate of 10 to 12 breaths per minute (choice D) is indicative of respiratory depression, a sign of magnesium toxicity. Thus, choice C is the best assessment to indicate a therapeutic level of medication in a patient with preeclampsia taking magnesium sulfate.

Correct Answer: D

Rationale: Correct Answer: D - Removing all of the patient�s metallic jewelry. Rationale: 1. Safety: Metallic objects can be attracted by the MRI magnet, causing harm to the patient and disrupting the imaging process. 2. Artifact Prevention: Metallic objects can produce artifacts on the MRI images, affecting the diagnostic quality. 3. Patient Comfort: Removing jewelry ensures the patient's comfort during the scan, avoiding discomfort or injury. Summary of Incorrect Choices: A: Not eating or drinking before an MRI is important, but it is not the most crucial action compared to patient safety and image quality. B: Colon cleansing may be necessary for certain types of MRI scans, but it is not universally required and is not the most important action. C: Pain medication may be important for patient comfort, but it is not essential for the actual MRI procedure and does not impact safety or image quality.

Correct Answer: C

Rationale: The correct answer is C: Monitor the patient for fever, rash, and difficulty breathing. The rationale is as follows: 1. Renal calculus obstruction can lead to complications such as infection, so monitoring for fever is crucial. 2. Rash can indicate an allergic reaction to the contrast dye used in the procedure. 3. Difficulty breathing may signal a severe reaction or complications. Summary: A: Turning the patient on the right side does not directly address the urgent need to monitor for potential complications. B: While fluid intake is important, it is not the immediate priority when the patient is at risk of developing complications. D: Administering narcotic medications may be necessary for pain relief but does not address the potential emergent issues related to the obstruction.

Correct Answer: A

Rationale: The correct answer is A: Tumor lysis syndrome (TLS). In this scenario, the oncology patient has completed treatment for non-Hodgkin lymphoma. TLS is a potential complication post-treatment due to the rapid breakdown of cancer cells, leading to release of intracellular contents like potassium, phosphorus, and uric acid into the bloodstream. This can result in electrolyte imbalances, renal failure, and cardiac arrhythmias. The nurse should assess for signs such as hyperkalemia, hyperphosphatemia, hypocalcemia, and elevated uric acid levels. Monitoring renal function and fluid status is crucial. Summary of other choices: B: Syndrome of inappropriate ADH (SIADH) is characterized by excessive release of antidiuretic hormone leading to water retention and dilutional hyponatremia. Not typically associated with post-treatment complications in oncology patients. C: Disseminated intravascular coagulation (DIC)