Foundations and Adult Health Nursing Test Bank

Correct Answer: B

Rationale: The patient who had a left total hip replacement surgery due to osteoarthritis needs to strictly follow the postoperative teaching of being shown how to gently irrigate the external auditory canal because this instruction is unrelated to a hip replacement surgery. The other options are not relevant to the surgery and patient's condition. Option A about airplane travel, Option C about dizziness, and Option D about hair washing are not appropriate instructions for a patient who had a hip replacement. It is important for healthcare providers to give accurate and relevant postoperative instructions to help the patient recover successfully.

Correct Answer: A

Rationale: The right being violated in this scenario is the right to obtain from his physician complete current information concerning his diagnosis, treatment, and prognosis. Patients have the right to be fully informed about their health status and to understand the details of their condition, treatment options, and likely outcomes. Withholding this information can prevent the patient from participating in their own care decisions and can violate their autonomy and right to make informed choices about their health.

Correct Answer: C

Rationale: It is essential for nurses to record vital signs and notes on a patient as soon as they obtain them. This allows for accurate and timely documentation of crucial information related to the patient's health status. By recording the information promptly, nurses can ensure that they do not forget important details and can provide effective care based on accurate data. Waiting for lunch break or after completing other tasks can lead to delays in documentation, which may compromise patient care and safety. Therefore, the ideal and proper time for recording vital signs and notes is immediately after obtaining them.

Correct Answer: A

Rationale: Lactulose is the most effective nursing intervention in preventing and managing hepatic encephalopathy in patients with cirrhosis. Lactulose works by promoting the elimination of ammonia in the colon through its laxative effect, thereby reducing ammonia levels in the blood. High ammonia levels are associated with the development of hepatic encephalopathy. By administering lactulose as prescribed, nurses can help reduce the risk of encephalopathy and manage symptoms effectively. Monitoring serum ammonia levels is important in assessing the effectiveness of lactulose therapy, but administering lactulose is the primary nursing intervention in this situation. Dietary protein restriction is also commonly recommended; however, lactulose administration is the most vital intervention in this scenario. Additionally, encouraging increased fluid intake is important for overall liver health but is not as specific to preventing and managing hepatic encephalopathy as administering lactulose.

Correct Answer: C

Rationale: The correct statement regarding the use of decongestant nasal sprays is that "Nasal sprays should not be used for more than three days because it can worsen congestion." Prolonged use of decongestant nasal sprays can lead to rebound congestion, where the congestion worsens with extended use. Therefore, it is important to limit the use of these sprays to avoid this side effect. It is recommended to use decongestant nasal sprays for no longer than three consecutive days.