Adult Health Med Surg Nursing Test Banks

Correct Answer: A

Rationale: Wearing a mask is an essential infection control measure to prevent the spread of respiratory illnesses, including COVID-19. By wearing a mask, Nurse Emma can reduce the risk of inhaling or exhaling respiratory droplets that may contain infectious particles, thus helping to protect herself and the family members she is visiting. Masks are particularly crucial when interacting with individuals who are sick or when physical distancing may be challenging. While using gloves, face shields, and gowns are also important infection control measures in certain situations, wearing a mask is the most relevant and effective measure during a home visit to prevent respiratory transmission of infections.

Correct Answer: C

Rationale: The most likely causative agent in this scenario is Borrelia burgdorferi, which is the bacterium responsible for causing Lyme disease. The classic presentation of Lyme disease includes fever, malaise, and a skin lesion resembling a "bull's eye" rash, known as erythema migrans. This rash typically appears at the site of a tick bite. If left untreated, Lyme disease can progress to involve multiple organ systems and lead to more severe complications. Plasmodium falciparum is the causative agent of malaria, which typically presents with symptoms such as fever, chills, and fatigue, but it does not cause a "bull's eye" rash. Trypanosoma cruzi is the parasite responsible for Chagas disease, which presents with symptoms such as fever, swelling at the site of entry (typically the bite wound), and enlarged lymph nodes, but it does not

Correct Answer: A

Rationale: Flexibility is the most important criterion in budgeting because it allows for adjustments to be made as circumstances change. Budgeting is a dynamic process, and having a flexible budget enables organizations or individuals to adapt to unexpected changes in income or expenses. This helps in ensuring that resources are allocated efficiently and effectively to meet the overall financial goals. Consistency, standardization, and cost-effectiveness are also important considerations in budgeting, but flexibility is key to successfully managing financial resources in a changing environment.

Correct Answer: C

Rationale: It is essential for the nurse to document important observations made during a tracheostomy procedure, and this includes the amount, color, and consistency of sputum as well as the appearance of the incision. Monitoring these factors helps assess the patient's respiratory status, risk of infection, and wound healing progress. Ensuring detailed documentation in this area allows for timely intervention if there are any concerning changes observed post-procedure. Observations such as the response of the patient, vital signs during the procedure, and patient behavior are also important but may be documented separately from the specific details related to sputum, incision appearance, and wound care.

Correct Answer: B

Rationale: A temperature of 39.8 degrees Celsius (103.6 degrees Fahrenheit) in a patient following abdominal surgery and ongoing blood transfusion may indicate an ongoing potential infection. During surgery, the body is exposed to various microorganisms, and the stress of surgery can weaken the immune system, making the patient more susceptible to infections. Blood transfusions also carry a risk of introducing infections if not properly screened. Therefore, in this situation, an elevated temperature may be a sign that an infection is developing, and prompt notification of the surgeon is important for further evaluation and management.