foundation of nursing questions and answers

Correct Answer: D

Rationale: The correct answer is D because documenting the patient's pain intensity using a pain scale (8 out of 10) is crucial for assessing the severity of the chest pain. This information helps in determining the appropriate intervention and monitoring the effectiveness of treatment. Choice A is irrelevant as it does not provide any useful information about the patient's condition. Choice B is important for neurological assessment but not specifically related to chest pain. Choice C is not as critical as knowing the current pain level.

Correct Answer: A

Rationale: The correct answer is A: Palliative surgery. In this scenario, the patient's colon cancer has already progressed to stage IV with metastasis to the liver, indicating an advanced and incurable condition. Palliative surgery aims to alleviate symptoms, improve quality of life, and prolong survival without aiming for a cure. Reconstructive surgery (B) is typically done to restore form or function, which is not the primary goal in this case. Salvage surgery (C) is usually performed to rescue a situation where initial treatment has failed, which is not the case here. Prophylactic surgery (D) is preventive and is not appropriate in a situation where cancer is already present and advanced.

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: B

Rationale: The correct answer is B: In fact, glaucoma usually requires lifelong treatment with medications. 1. Glaucoma is a chronic condition characterized by increased intraocular pressure. 2. Lifelong treatment is usually necessary to manage intraocular pressure and prevent vision loss. 3. Stopping medication prematurely can lead to worsening of the condition. 4. Therefore, the nurse should educate the patient about the need for ongoing medication to manage glaucoma effectively. Summary: A: Incorrect. Having a positive attitude is beneficial, but it does not shorten the duration of glaucoma treatment. C: Incorrect. The target intraocular pressure is usually below 21 mm Hg, not 50 mm Hg. D: Incorrect. Glaucoma treatment is typically long-term, not limited to 6 months.

Correct Answer: C

Rationale: The correct answer is C - bleeding at IV insertion site. This finding could indicate a major complication following an abruption placenta, such as disseminated intravascular coagulation (DIC) or hypovolemic shock. Bleeding at the IV site suggests a systemic issue affecting the patient's coagulation status. Choices A, B, and D are not directly indicative of a major complication following an abruption placenta. Urine output, blood pressure, and respiratory rate are important parameters to monitor but do not specifically point to a major complication in this context.