Fundamentals of Nursing Practice Quiz 32

Answer: D – Evaluation

Explanation: In the evaluation step of the nursing process, the nurse must decide whether the patient has achieved the expected outcome that was identified in the planning phase.

Answer: A – White potatoes

Explanation: The main sources of vitamin A are yellow and green vegetables (such as carrots, sweet potatoes, squash, spinach, collard greens, broccoli, and cabbage) and yellow fruits (such as apricots, and cantaloupe). Animal sources include liver, kidneys, cream, butter, and egg yolks.

Answer: D – Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity

Explanation: Maintaining the drainage tubing and collection bag level with the patient’s bladder could result in reflux of urine into the kidney. Irrigating the bladder with Neosporin and clamping the catheter for 1 hour every 4 hours must be prescribed by a physician.

Answer: D – All of the above

Explanation: The ELISA test of venous blood is used to assess blood and potential blood donors to human immunodeficiency virus (HIV). A positive ELISA test combined with various signs and symptoms helps to diagnose acquired immunodeficiency syndrome (AIDS).

Answer: A – Subclavian and jugular veins

Explanation: Total Parenteral Nutrition (TPN) requires the use of a large vessel, such as the subclavian or jugular vein, to ensure rapid dilution of the solution and thereby prevent complications, such as hyperglycemia. The brachial and femoral veins usually are contraindicated because they pose an increased risk of thrombophlebitis.

Answer: D – Having the patient shower with an antiseptic soap on the evening before and the morning of surgery

Explanation: Studies have shown that showering with an antiseptic soap before surgery is the most effective method of removing microorganisms from the skin, Shaving the site of the intended surgery might cause breaks in the skin, thereby increasing the risk of infection; however, if indicated, shaving, should be done immediately before surgery, not the day before, A topical antiseptic would not remove microorganisms and would be beneficial only after proper cleaning and rinsing, Tub bathing might transfer organisms to another body site rather than rinse them away.

Answer: C – Leg muscles

Explanation: The leg muscles are the strongest muscles in the body and should bear the greatest stress when lifting. Muscles of the abdomen, back, and upper arms may be easily injured.

Answer: C – An impaired or traumatized blood vessel wall

Explanation: The factors, known as Virchow’s triad, collectively predispose a patient to thrombophlebitis; impaired venous return to the heart, blood hypercoagulability, and injury to a blood vessel wall, Increased partial thromboplastin time indicates a prolonged bleeding time during fibrin clot formation, commonly the result of anticoagulant (heparin) therapy, Arterial blood disorders (such as pulsus paradoxus) and lung diseases (such as COPD) do not necessarily impede venous return of injured vessel walls.

Answer: A – Respiratory acidosis, atelectasis, and hypostatic pneumonia

Explanation: Because of restricted respiratory movement, a recumbent, immobilize patient is at particular risk for respiratory acidosis from poor gas exchange; atelectasis from reduced surfactant and accumulated mucus in the bronchioles, and hypostatic pneumonia from bacterial growth caused by stasis of mucus secretions.

Answer: B – Urine retention, bladder distention, and infection

Explanation: The immobilized patient commonly suffers from urine retention caused by decreased muscle tone in the perineum. This leads to bladder distention and urine stagnation, which provide an excellent medium for bacterial growth leading to infection, Immobility also results in more alkaline urine with excessive amounts of calcium, sodium and phosphate, a gradual decrease in urine production, and an increased specific gravity.