foundation of nursing practice questions

foundation of nursing practice questions Related

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A nurse is evaluating a nursing assistive personnel’s(NAP) care for a patient with an indwelling catheter. Which action by the NAP will cause the nurse to intervene?

  • A. Emptying the drainage bag when half full
  • B. Kinking the catheter tubing to obtain a urine specimen
  • C. Placing the drainage bag on the side rail of the patient’s bed
  • D. Securing the catheter tubing to the patient’s thigh
Correct Answer: C

Rationale: Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. A key intervention to prevent catheter-associated urinary tract infections is prevention of urine back flow from the tubing and bag into the bladder. All the other actions are correct procedures and do not require immediate follow-up. The drainage bag should be emptied when it is half full to prevent tension and pulling on the catheter, which could result in trauma to the urethra and increase the risk for urinary tract infections. Urine specimens are traditionally obtained by temporarily kinking the tubing, while securing the catheter tubing to the patient’s thigh prevents catheter dislodgment and tissue injury.

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While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?

  • A. Stopping the administration of the drug immediately
  • B. Notifying the patients physician
  • C. Continuing the infusion but decreasing the rate
  • D. Applying a warm compress to the infusion site .
Correct Answer: A

Rationale: Swelling and pain at the IV site can indicate extravasation, which is the leakage of a vesicant medication like doxorubicin hydrochloride into the surrounding tissues. It is crucial to stop the administration of the drug immediately upon suspicion of extravasation to minimize tissue damage and potential complications. By stopping the administration promptly, further harm can be prevented, and early interventions can be initiated to mitigate the effects of the extravasation. Notifications to the physician and appropriate actions, such as aspiration of any remaining drug, may follow after discontinuing the infusion.

A nurse needs to begin discharge planning fora patient admitted with pneumonia and a congested cough. When is the besttime the nurse should start discharge planningfor this patient?

  • A. Upon admission
  • B. Right before discharge
  • C. After the congestion is treated
  • D. When the primary care provider writes the order
Correct Answer: A

Rationale: The best time for a nurse to start discharge planning for a patient admitted with pneumonia and a congested cough is upon admission. Starting discharge planning early allows the healthcare team to identify the patient's needs, plan for the appropriate level of care, and ensure a smooth transition out of the hospital. Waiting until right before discharge or after the congestion is treated may lead to rushed or incomplete planning, potentially compromising the patient's recovery and post-discharge care. Additionally, discharge planning is not dependent on the primary care provider writing an order, as nurses can initiate teaching and planning proactively to support the patient's optimal recovery and transition. By beginning discharge planning upon admission, the healthcare team can address any potential barriers to discharge and ensure the patient's needs are met for a successful recovery process.

To honor cultural values of patients from different ethnic/religious groups, which actions demonstrate culturally sensitive care by the nurse? (Select allthat apply.)

  • A. Allows fasting on Yom Kippur for a Jewish patient
  • B. Allows caffeine drinks for a Mormon patient
  • C. Serves no ham products to a Muslim patient
  • D. Serves kosher foods to a Christian patient
Correct Answer: A

Rationale: A. Allowing fasting on Yom Kippur for a Jewish patient demonstrates culturally sensitive care by respecting and accommodating the religious practices of the patient. Yom Kippur is an important day of fasting and repentance in the Jewish faith, and by allowing the patient to observe this practice, the nurse shows understanding and support.

A patients current antiretroviral regimen includes nucleoside reverse transcriptase inhibitors (NRTIs). What dietary counseling will the nurse provide based on the patients medication regimen?

  • A. Avoid high-fat meals while taking this medication.
  • B. Limit fluid intake to 2 liters a day.
  • C. Limit sodium intake to 2 grams per day.
  • D. Take this medication without regard to meals.
Correct Answer: D

Rationale: Nucleoside reverse transcriptase inhibitors (NRTIs) are a class of antiretroviral medications typically recommended to be taken without regard to meals. This means that these medications can be taken with or without food. It is important to follow the specific instructions provided by the healthcare provider regarding the timing of medication administration. Taking NRTIs without regard to meals helps ensure consistent absorption of the medication and can help maintain steady drug levels in the body. There are no specific dietary restrictions associated with NRTIs in terms of meal timing or composition.

The nurse is providing care for a patient who has benefited from a cochlear implant. The nurse should understand that this patients health history likely includes which of the following? Select all that apply.

  • A. The patient was diagnosed with sensorineural hearing loss.
  • B. The patients hearing did not improve appreciably with the use of hearing aids.
  • C. The patient has deficits in peripheral nervous function.
  • D. The patients hearing deficit is likely accompanied by a cognitive deficit. E) The patient is unable to lip-read.
Correct Answer: A

Rationale: A. The patient was diagnosed with sensorineural hearing loss.

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