foundation of nursing questions

Correct Answer: C

Rationale: The correct answer is C: �Drink your nightly glass of milk earlier in the evening.� By suggesting the patient to drink milk earlier, it allows more time for the body to process and excrete the fluids before bedtime, reducing the likelihood of bedwetting. This intervention targets the root cause of the issue by addressing the timing of fluid intake. Explanation for why the other choices are incorrect: A: �Set your alarm clock to wake you every 2 hours, so you can get up to void.� This intervention disrupts the patient's sleep pattern and may not address the underlying cause of bedwetting. B: �Line your bedding with plastic sheets to protect your mattress.� This intervention focuses on managing the consequences of bedwetting rather than preventing it. D: �Empty your bladder completely before going to bed.� While important, this suggestion alone may not be sufficient to address the timing of fluid intake, which is crucial in reducing bedwetting frequency.

Correct Answer: B

Rationale: The correct answer is B: Montelukast (Singulair). Montelukast is a leukotriene receptor antagonist that helps prevent asthma exacerbations by reducing inflammation in the airways. It is used as a maintenance medication to control and prevent asthma symptoms. Diphenhydramine (A) is an antihistamine used for allergies, not asthma prevention. Albuterol sulfate (C) is a rescue inhaler used for acute asthma symptoms, not prevention. Epinephrine (D) is used for severe allergic reactions (anaphylaxis), not asthma prevention.

Correct Answer: C

Rationale: The correct answer is C, Glucosuria. Preeclampsia is characterized by hypertension, proteinuria, and edema. Glucosuria is not a typical symptom of preeclampsia. Glucosuria is more commonly associated with gestational diabetes, which is a separate condition from preeclampsia. Therefore, in a pregnant patient at risk for preeclampsia, the presence of glucosuria would not be indicative of preeclampsia. The other choices, edema, proteinuria, and hypertension, are all common clinical signs seen in patients with preeclampsia.

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: 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.