foundation of nursing practice questions

foundation of nursing practice questions Related

Review foundation of nursing practice questions related questions and content

A patient who has AIDS is being treated in the hospital and admits to having periods of extreme anxiety. What would be the most appropriate nursing intervention?

  • A. Teach the patient guided imagery.
  • B. Give the patient more control of her antiretroviral regimen.
  • C. Increase the patients activity level.
  • D. Collaborate with the patients physician to obtain an order for hydromorphone.
Correct Answer: A

Rationale: The most appropriate nursing intervention for a patient with AIDS experiencing extreme anxiety is to teach the patient guided imagery. Guided imagery is a relaxation technique that can help the patient reduce anxiety levels, promote a sense of calm, and improve overall well-being. By teaching the patient how to use guided imagery, the nurse empowers the patient to manage her anxiety in a non-pharmacological way. This intervention promotes self-care and allows the patient to have a tool to use independently beyond the hospital setting. Giving the patient more control of her antiretroviral regimen may be beneficial for adherence but does not directly address the anxiety symptoms. Increasing the patient's activity level may be helpful for overall well-being but may not specifically target the extreme anxiety. Collaborating with the patient's physician to obtain an order for hydromorphone, a potent opioid medication, is not appropriate unless it is indicated for severe pain management, not anxiety.

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The nurse is caring for a patient who has undergone a mastoidectomy. In an effort to prevent postoperative infection, what intervention should the nurse implement?

  • A. Teach the patient about the risks of ototoxic medications.
  • B. Instruct the patient to protect the ear from water for several weeks.
  • C. Teach the patient to remove cerumen safely at least once per week.
  • D. Instruct the patient to protect the ear from temperature extremes until healing is complete.
Correct Answer: B

Rationale: After a mastoidectomy, the ear should be protected from water for several weeks. This is because exposing the area to water can increase the risk of infection. Keeping the ear dry allows the surgical site to heal properly and reduces the likelihood of postoperative complications such as infection. Therefore, instructing the patient to protect the ear from water is an important intervention to prevent postoperative infection following a mastoidectomy.

A patient has a history of drug use and is screened for hepatitis B during the first trimester. Which action is most appropriate?

  • A. Practice respiratory isolation.
  • B. Plan for retesting during the third trimester.
  • C. Discuss the recommendation to bottle feed her baby.
  • D. Anticipate administering the vaccination for hepatitis B as soon as possible
Correct Answer: B

Rationale: A person who has a history of high-risk behaviors, such as drug use, should be retested for hepatitis B during the third trimester. This is because the virus can have a long incubation period before showing up in blood tests. Retesting in the third trimester ensures that if the infection was acquired after the initial screening, it will be detected in time to provide appropriate care and interventions. Retesting is important in high-risk individuals to ensure proper management and prevention of hepatitis B transmission.

A nurse is providing care to a group of patients.Which situation will require the nurse to obtain a telephone order?

  • A. As the nurse and health care provider leave a patient’s room, the primary care provider gives the nurse an order.
  • B. At 0100, a patient’s blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated with blood.
  • C. At 0800, the nurse and health care provider make rounds, and the primary care provider tells the nurse a diet order.
  • D. A nurse reads an order correctly as written by the health care provider in the patient’s medical record
Correct Answer: B

Rationale: In this situation, the nurse needs to obtain a telephone order because the patient's condition has changed significantly. The drop in blood pressure from 120/80 to 90/50 along with the saturated incision dressing indicates a potential complication or need for immediate intervention. The nurse must act quickly to address the situation and may require additional orders from the primary care provider over the phone to manage the patient's condition effectively. The urgency and critical nature of the situation necessitate obtaining a telephone order promptly to ensure the best outcome for the patient.

An older adult patient has been diagnosed with macular degeneration and the nurse is assessing him for changes in visual acuity since his last clinic visit. When assessing the patient for recent changes in visual acuity, the patient states that he sees the lines on an Amsler grid as being distorted. What is the nurses most appropriate response?

  • A. Ask if the patient has been using OTC vasoconstrictors.
  • B. Instruct the patient to repeat the test at different times of the day when at home.
  • C. Arrange for the patient to visit his ophthalmologist.
  • D. Encourage the patient to adhere to his prescribed drug regimen. .
Correct Answer: C

Rationale: Distorted lines on an Amsler grid can be an indication of changes in central vision, which is commonly seen in macular degeneration. Therefore, it is crucial for the nurse to arrange for the patient to visit his ophthalmologist promptly for further evaluation and management. The ophthalmologist will be able to determine the severity of the visual changes, provide appropriate treatment options, and closely monitor the progression of macular degeneration. This proactive approach ensures that the patient receives timely and specialized care for his condition. Options A, B, and D do not directly address the urgency of the situation and the need for specialized ophthalmologic evaluation in cases of macular degeneration.

A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse’s action?

  • A. To promote autonomy
  • B. To use common courtesy
  • C. To establish trustworthiness
  • D. To standardize communication
Correct Answer: D

Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.

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