foundation of nursing practice questions

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.

Correct Answer: B

Rationale: B. Overall psychological functioning: It is crucial for the home care nurse to assess the patient's overall psychological functioning after a total mastectomy without reconstruction. The patient may be experiencing emotional distress, body image disturbances, anxiety, or depression related to the surgery and changes in physical appearance. The nurse should evaluate the patient's coping mechanisms, emotional well-being, and any signs of psychological implications to provide appropriate support and referral for mental health services if needed.

Correct Answer: D

Rationale: Radical trachelectomy is a surgical procedure that involves the removal of the cervix while preserving the uterus. This procedure is often offered to young women diagnosed with early-stage cervical cancer who wish to preserve their fertility and have children in the future. By removing the cervix and part of the upper vagina, while leaving the uterus intact, radical trachelectomy offers these patients a chance at preserving their ability to conceive and carry a pregnancy to term. It is a fertility-sparing option in the management of cervical cancer, particularly in younger patients like the 25-year-old mentioned in the question.

Correct Answer: B

Rationale: A nonmobile mass with irregular edges would most strongly suggest that the patient's lump is cancerous. Breast cancer lumps typically do not move easily and have irregular, poorly defined edges. These characteristics are concerning because they can indicate an invasive and aggressive growth pattern. Additionally, the fact that the lump is painless is another feature that raises suspicion for malignancy. It is important for the patient to undergo further evaluation, possibly including a mammogram, ultrasound, and biopsy, to determine the nature of the lump and provide appropriate treatment.

Correct Answer: A

Rationale: Nausea and vomiting are common adverse effects of chemotherapy. Administering an antiemetic helps to prevent or reduce these symptoms in patients undergoing chemotherapy. By managing nausea and vomiting, the patient's overall well-being and quality of life during treatment can be improved. Therefore, providing an antiemetic medication is essential in combating these adverse effects and promoting patient comfort and compliance with treatment.