foundations of nursing test bank

Correct Answer: C

Rationale: The correct answer is C: Risk for infection related to altered immunologic response. This is the priority nursing diagnosis for a patient preparing for hematopoietic stem cell transplant (HSCT) because the patient's immune system will be severely compromised post-transplant, leading to a high risk of infections. It is crucial to prioritize infection prevention to ensure the patient's safety and well-being. Choice A is incorrect because while fatigue is common in cancer patients, it is not the priority in this case where infection risk is higher. Choice B is incorrect as altered nutrition can be addressed after managing the risk for infection. Choice D is incorrect as body image disturbance is important but not as critical as preventing infections in this highly vulnerable patient population.

Correct Answer: B

Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection. A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal. C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem. D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.

Correct Answer: B

Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction. Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.

Correct Answer: B

Rationale: The correct answer is B: Total placenta previa. In this condition, the placenta completely covers the cervix, posing a risk of severe bleeding during vaginal delivery. Cesarean birth is necessary to avoid potential life-threatening complications for both the mother and the baby. Partial abruptio placentae (choice A) involves premature separation of the placenta, but it doesn't always require a cesarean birth. Ectopic pregnancy (choice C) occurs when the fertilized egg implants outside the uterus, typically requiring surgical intervention but not always a cesarean birth. Eclampsia (choice D) is a serious condition characterized by high blood pressure and seizures, but it doesn't always necessitate cesarean birth unless there are other complications that require it.

Correct Answer: A

Rationale: The correct answer is A: Application of topical antibiotic ointment. After enucleation, there is a risk of infection at the surgical site. By applying topical antibiotic ointment as directed, the patient can help prevent infection and promote healing. This is a crucial aspect of postoperative care. B: Maintenance of a supine position for the first 48 hours postoperative is incorrect. Patients may be advised to avoid lying flat on their back to prevent complications such as pressure on the surgical site. C: Fluid restriction to prevent orbital edema is incorrect. Fluid restriction is not typically necessary post-enucleation unless specifically advised by the healthcare provider. D: Administration of loop diuretics to prevent orbital edema is incorrect. Loop diuretics are not typically used for preventing orbital edema post-enucleation. E: Use of an ocular pressure dressing is incorrect. While dressings may be used postoperatively, the application of topical antibiotic ointment is more