foundation of nursing questions and answers

Correct Answer: D

Rationale: The correct answer is D because cleansing the meatus with circular strokes starting at the meatus and moving outward helps prevent the introduction of bacteria into the urethra. This technique minimizes the risk of urinary tract infections. Holding the shaft at a 60-degree angle (A) or with the dominant hand (B) is not necessary for catheter insertion. Cleansing the meatus 3 times with the same cotton ball (C) can introduce more bacteria and is not recommended.

Correct Answer: D

Rationale: The correct answer is D: Pneumocystis pneumonia. This is the most common life-threatening infection in HIV-positive patients with low CD4+ counts. Pneumocystis pneumonia is caused by the opportunistic pathogen Pneumocystis jirovecii, which can lead to severe respiratory distress and mortality in immunocompromised individuals. The other choices, A: Salmonella infection, B: Mycobacterium tuberculosis, and C: Clostridium difficile, can also cause infections in HIV-positive patients, but they are not as commonly associated with life-threatening complications in this population compared to Pneumocystis pneumonia. It is crucial for the nurse to prioritize assessment for signs and symptoms of Pneumocystis pneumonia in this patient to promptly intervene and prevent further complications.

Correct Answer: C

Rationale: The correct answer is C because anesthetics used during surgery can decrease bladder contractility, leading to urinary retention. By inserting an indwelling catheter, the nurse ensures proper drainage of urine and prevents bladder distention. This helps to maintain the patient's comfort and prevent complications such as urinary retention and potential bladder injury. Choice A is incorrect because inserting a catheter is not primarily to prevent uncontrollable voiding during surgery. Choice B is incorrect as local trauma does not promote excessive urine incontinence necessitating catheterization. Choice D is incorrect because the primary purpose of catheter insertion is not to prevent interruption of the procedure by bathroom breaks.

Correct Answer: A

Rationale: The correct answer is A because it shows empathy and offers the patient an opportunity to express their feelings. By acknowledging the patient's frustration and anger, the nurse validates their emotions and creates a safe space for communication. This response promotes trust and understanding, which are crucial in building a therapeutic relationship. Choice B is incorrect because it immediately jumps to teaching coping strategies without addressing the patient's emotional state. Choice C is incorrect as it generalizes the patient's feelings without directly engaging with their specific concerns. Choice D is incorrect as it sounds dismissive and may make the patient feel judged or misunderstood. These responses lack the empathetic approach needed to effectively support the patient in this situation.

Correct Answer: B

Rationale: The correct answer is B: Does she have a sense of peace of mind and a purpose to her life? This question is crucial during a spiritual assessment because it addresses the patient's emotional well-being and coping mechanisms in the face of a terminal diagnosis. It helps assess the patient's spiritual beliefs, values, and sources of strength, which can impact their ability to find meaning and comfort during difficult times. It also provides insights into the patient's resilience and ability to navigate their emotions and find peace amidst uncertainty. Choice A is incorrect because it focuses on the patient's ability to deliver negative news to her family, which is important but not as central to the patient's spiritual well-being in this context. Choice C is incorrect as it assumes the patient needs to let go of her husband, which may not be relevant to her spiritual assessment. Choice D is incorrect as it centers on bargaining with God for a cure, which may not be reflective of the patient's spiritual beliefs or needs.