foundation of nursing practice questions

Correct Answer: A

Rationale: The most critical assessment parameter to include in the initial assessment of a patient with a brain tumor scheduled for surgery is the gag reflex. The gag reflex is a protective mechanism that prevents the entry of foreign objects into the airway and lungs. Patients undergoing brain tumor resection may be at risk for impaired gag reflex due to the effects of the tumor on cranial nerves or related structures. Identifying any impairment in the gag reflex is essential to prevent aspiration during and after the surgical procedure. Monitoring the gag reflex allows the healthcare team to take necessary precautions to protect the patient's airway and prevent complications. Therefore, assessing the gag reflex is crucial in the care of a patient with a brain tumor undergoing surgery.

Correct Answer: A

Rationale: When obtaining a 24-hour urine specimen, it is important to keep the urine collection container on ice if indicated. Storing the urine on ice helps to preserve the integrity of certain components in the specimen that might be affected by higher temperatures. Some tests require the sample to be kept cool to ensure accurate results. Therefore, the nurse should follow the specific instructions provided for the collection and storage of the urine specimen.

Correct Answer: D

Rationale: Immunotherapy, also known as allergy shots, is a form of treatment that can help reduce symptoms for individuals with severe allergies to substances such as pollen, dust mites, or pet dander. This treatment involves exposing the patient to small, increasing doses of the allergen over time to help the immune system gradually build up a tolerance. Patients with severe allergies to grass and tree pollen would most likely benefit from immunotherapy as it can help reduce their allergy symptoms and improve their quality of life. On the other hand, individuals with anaphylactic reactions to insect stings (Choice A), allergies to eggs and dairy (Choice B), or a positive tuberculin skin test (Choice C) are not typically candidates for immunotherapy as their conditions are not related to the type of allergies that are commonly treated with this method.

Correct Answer: B

Rationale: The most appropriate action for the nurse to take in this situation is to apply warm compresses to the patient's lower abdomen. Abdominal bloating and an increase in abdominal girth can be common following a vaginal hysterectomy. Applying warm compresses to the lower abdomen can help to relieve bloating and discomfort by promoting relaxation of the abdominal muscles and increasing blood flow to the area. This can provide relief to the patient and support their recovery process. Applying warm compresses is a non-invasive intervention that can be easily implemented and is commonly used in post-operative care to address abdominal discomfort.

Correct Answer: C

Rationale: Rheumatoid arthritis shows marked improvement during pregnancy, although the reason for this is not entirely clear. The improvement is often significant, leading to relief from symptoms for many pregnant individuals with this condition. However, it's important to note that this improvement is temporary, as relapse typically occurs within 36 months postpartum. The exact mechanisms behind this temporary improvement are not fully understood, but hormones and changes in the immune system during pregnancy are believed to play a role in modifying the disease process.