Adult Health Nursing Test Bank

Correct Answer: A

Rationale: Correct Answer: A - sterile clamps Rationale: 1. **Immediate action**: Sterile clamps are essential to clamp the chest tube to prevent air from entering the pleural space. 2. **Prevent lung collapse**: Clamping the tube will prevent lung collapse and maintain positive pressure in the pleural space. 3. **Buy time**: By clamping the tube, you buy time to properly reattach the tube or secure it with a new connection. 4. **Safety**: Sterile clamps are a quick and effective solution to prevent a potentially life-threatening situation. Summary of other choices: B: Sterile dressing - Not the first priority as the immediate concern is preventing air from entering the pleural space. C: Another chest tube - Not necessary initially as clamping can buy time to reattach the disconnected tube. D: A bottle of sterile water - Not needed for emergency management of a disconnected chest tube.

Correct Answer: B

Rationale: The correct answer is B: Disseminated intravascular coagulation (DIC). In DIC, there is widespread activation of coagulation leading to consumption of clotting factors, resulting in prolonged PT and aPTT, low fibrinogen levels, and elevated D-dimer. This pattern matches the laboratory findings in the patient. In liver cirrhosis (choice A), there is a decrease in clotting factors synthesis, leading to prolonged PT but not aPTT. Hemophilia A (choice C) is a genetic disorder that affects specific clotting factors, typically leading to prolonged aPTT but not PT. Vitamin K deficiency (choice D) impairs the synthesis of clotting factors, leading to prolonged PT but not aPTT and low levels of factors II, VII, IX, and X.

Correct Answer: A

Rationale: Encouraging early ambulation and progressive activity as tolerated is the most appropriate nursing intervention to promote optimal recovery for a postpartum client who delivered via cesarean section. Early ambulation helps prevent complications such as blood clots, pneumonia, and constipation. It also promotes circulation and facilitates healing by reducing the risk of postoperative complications. Progressive activity helps the client regain strength, mobility, and independence, which are essential for a speedy recovery. Restoring normal movement will also help decrease discomfort and improve the client's overall well-being. In contrast, restricting movement may lead to complications and delayed recovery. Administering oral analgesics as needed is important for pain management, but promoting early ambulation is essential for optimal recovery. Heat packs should not be applied to the incision site as they can increase the risk of infection and interfere with proper wound healing.

Correct Answer: B

Rationale: Correct Answer: B Rationale: 1. Asking the patient about their cultural background and preferences shows respect for their individuality and acknowledges the importance of cultural competence in providing person-centered care. 2. It allows the nurse to gain valuable insights into the patient's beliefs, values, and practices, enabling them to deliver culturally appropriate care. 3. By prioritizing this aspect, the nurse can establish rapport, build trust, and enhance communication with the patient, leading to better outcomes. 4. Choices A, C, and D are incorrect as they either involve assumptions, avoidance, or disregard for the patient's cultural background, which can lead to misunderstandings, discomfort, and ineffective care.

Correct Answer: B

Rationale: The correct answer is B: Herpes simplex virus infection. The presentation of a painful, vesicular rash following a linear pattern on the left forearm is characteristic of herpes simplex virus infection, specifically herpes zoster (shingles). The linear pattern is due to the virus following a specific nerve pathway. This is different from the other choices - A: Allergic contact dermatitis typically presents as a diffuse rash at the site of contact with an allergen, not a linear pattern. C: Scabies presents with burrows and papules, not vesicles in a linear pattern. D: Poison ivy dermatitis causes a diffuse rash, not a linear vesicular rash.