foundation of nursing practice questions

foundation of nursing practice questions Related

Review foundation of nursing practice questions related questions and content

A patient has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurses most appropriate action?

  • A. Reassure the patient that this is an age-related change in vision.
  • B. Arrange for the patient to have her visual acuity assessed.
  • C. Arrange for the patient to be assessed for macular degeneration.
  • D. Facilitate tonometry testing.
Correct Answer: C

Rationale: The most appropriate action for the home health nurse to take in this situation where a patient reports distortions when looking at an Amsler grid is to arrange for the patient to be assessed for macular degeneration. Distortions in straight lines on an Amsler grid are a common early symptom of macular degeneration, a progressive eye condition that affects central vision. Macular degeneration is a leading cause of vision loss in older adults, making assessment and early intervention crucial in preserving vision. It is important for the nurse to take the patient's symptoms seriously and facilitate timely evaluation and management to prevent further vision loss. This would involve referring the patient to an ophthalmologist or an eye care specialist for a comprehensive evaluation and appropriate treatment.

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A patient with no prenatal care delivers a healthy male infant via the vaginal route, with minimal blood loss. During the labor period, vital signs were normal. At birth, significant maternal hypertension is noted. When the patient is questioned, she relates that there is history of heart disease in her family; but, that she has never been treated for hypertension. Blood pressure is treated in the hospital setting and the patient is discharged. The patient returns at her scheduled 6-week checkup and is found to be hypertensive. Which type of hypertension is the patient is exhibiting?

  • A. Pregnancy-induced hypertension (PIH)
  • B. Gestational hypertension
  • C. Preeclampsia superimposed on chronic hypertension
  • D. Undiagnosed chronic hypertension
Correct Answer: D

Rationale: The patient in this scenario exhibits signs of chronic hypertension, particularly due to the history of heart disease in her family, the postpartum persistence of elevated blood pressure, and the diagnosis of hypertension at the 6-week checkup. While pregnancy-induced hypertension (PIH), gestational hypertension, and preeclampsia can occur during pregnancy, they typically resolve within a few weeks after delivery. The fact that the patient's hypertension persists beyond the postpartum period suggests that she likely had preexisting, undiagnosed chronic hypertension. Therefore, option D is the most appropriate choice in this case.

For the patient who delivered at 6:30 AM on January 10, Rho(D) immune globulin (RhoGAM) must be administered prior to

  • A. 6:30 AM on January 13
  • B. 6:30 PM on January 13
  • C. 6:30 PM on January 14
  • D. 6:30 AM on January 15
Correct Answer: A

Rationale: Rho(D) immune globulin (RhoGAM) needs to be administered within 72 hours postpartum to Rh-negative patients who have given birth to Rh-positive infants to prevent Rh sensitization. The patient delivered at 6:30 AM on January 10, so the RhoGAM should be administered prior to that time on January 13, which is 72 hours postpartum. Therefore, the correct choice is A. 6:30 AM on January 10.

Draw up prescribed amount of sterile solution ordered.

  • A. 3, 2, 6, 1, 5, 4
  • B. 5, 6, 1, 2, 3, 4
  • C. 1, 5, 6, 3, 2, 4
  • D. 6, 5, 1, 3, 2, 4
Correct Answer: D

Rationale: The correct sequence for drawing up a prescribed amount of sterile solution ordered is as follows: 6, 5, 1, 3, 2, 4.

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.

The nurse is obtaining a 24-hour urine specimencollection from the patient. Which actions should the nurse take? (Select all that apply.)

  • A. Keeping the urine collection container on ice when indicated
  • B. Withholding all patient medications for the day
  • C. Irrigating the sample as needed with sterile solution
  • D. Testing the urine sample with a reagent strip by dipping it in the urine
Correct Answer: A

Rationale: When obtaining a 24-hour urine specimen, it is important to keep the urine collection container on ice if indicated. Storing the urine on ice helps to preserve the integrity of certain components in the specimen that might be affected by higher temperatures. Some tests require the sample to be kept cool to ensure accurate results. Therefore, the nurse should follow the specific instructions provided for the collection and storage of the urine specimen.

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