foundation of nursing questions

Correct Answer: B

Rationale: The correct answer is B: Thigh. When administering epinephrine during an anaphylactic reaction, the thigh is the recommended site due to its large muscle mass and quick absorption rate. Steps: 1. Remove safety cap. 2. Firmly push the auto-injector against the thigh until it clicks. 3. Hold in place for a few seconds. 4. Seek medical help immediately. Rationale for incorrect choices: A: Forearm - Not recommended due to smaller muscle mass and slower absorption. C: Deltoid muscle - Not preferred as it may not provide as rapid absorption as the thigh. D: Abdomen - Not ideal due to potential fat layers that could affect absorption speed.

Correct Answer: A

Rationale: The correct answer is A because it acknowledges the patient's symptoms, reassures monitoring, and addresses the cause. It validates his experience while offering a proactive approach. Choice B is incorrect as it dismisses the patient's symptoms and can cause distress. Choice C is incorrect because it generalizes the patient's experience and lacks individualized care. Choice D is incorrect as it may give false hope and oversimplifies the situation. A provides the best balance of empathy and information for the patient's well-being.

Correct Answer: A

Rationale: The correct answer is A: Foods. Anaphylaxis is a severe allergic reaction that can be triggered by foods, medications, insect stings, and other allergens. In this scenario, assessing for potential food allergies is crucial as food is one of the most common triggers for anaphylaxis. Foods like nuts, shellfish, and eggs are common culprits. Medications and insect stings (choices B and C) are also important triggers to consider in the assessment. Autoimmunity (choice D) is not a direct cause of anaphylaxis, as it involves the immune system attacking the body's own tissues rather than reacting to external allergens. Environmental pollutants (choice E) may trigger respiratory symptoms but are not typically associated with anaphylaxis.

Correct Answer: B

Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention. Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B. Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B. Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.

Correct Answer: B

Rationale: The correct answer is B: The patient is likely to experience resolution of conductive hearing loss after the procedure. This information is crucial to include in the preoperative teaching because it directly addresses the patient's expected outcome, providing reassurance and setting appropriate expectations. Stapedectomy with prosthesis insertion is a well-established treatment for otosclerosis-related conductive hearing loss. Choices A, C, and D are incorrect because they either provide misleading information (A, D) or are not directly relevant to the procedure or the patient's immediate postoperative experience (C). It is important to focus on accurate and relevant information to prepare the patient effectively for the upcoming surgery and its expected outcomes.