foundation of nursing questions

Correct Answer: C

Rationale: The correct answer is C: Monitoring the integrity of the surgical site. This is the priority intervention as it ensures early detection of any complications like infection or bleeding. The nurse should assess for signs of infection, such as redness, swelling, or drainage, and monitor for any changes in the wound appearance. Placing the patient in high Fowler's position (A) may be beneficial for comfort but is not the priority. Administering sitz baths (B) may be helpful for comfort but should not be the priority over monitoring the surgical site. Avoiding analgesics (D) unless the pain is unbearable is not appropriate as pain management is essential for the patient's comfort and recovery.

Correct Answer: B

Rationale: The correct answer is B: Scheduled analgesia should be administered around-the-clock to prevent pain. After undergoing a wide excision of the vulva, the patient is likely to experience significant pain. Scheduled analgesia ensures that the patient receives pain relief consistently, preventing pain from becoming severe. This approach helps to maintain a therapeutic level of pain control and improves patient comfort and satisfaction. Choice A is incorrect because withholding analgesia until the pain becomes unbearable can lead to unnecessary suffering and poor pain management. Choice C is incorrect as PRN dosing may result in inadequate pain relief and fluctuations in pain control. Choice D is incorrect as opioids are often necessary for postoperative pain management, and NSAIDs alone may not provide sufficient relief for the level of pain associated with a wide excision surgery.

Correct Answer: B

Rationale: The correct answer is B because assessing and promoting the patient's coping skills is essential in addressing the psychosocial needs of a patient with macular degeneration. By understanding how the patient is coping with the vision loss, the nurse can tailor interventions to support the patient effectively. This approach acknowledges the patient's emotional responses and helps them navigate the challenges associated with the condition. Choice A is incorrect as solely focusing on other senses may not address the psychological impact of vision loss. Choice C is incorrect as it dismisses the significant lifestyle changes the patient may experience. Choice D is incorrect as promoting hope for recovery may not be realistic in the case of irreversible conditions like macular degeneration.

Correct Answer: C

Rationale: The correct answer is C: Computed tomography with contrast solution. This procedure involves the use of contrast agents that can trigger anaphylaxis due to the patient's allergic reaction to the contrast solution. Contrast solutions contain substances like iodine, which can cause severe allergic reactions in some individuals. Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and requires immediate intervention. Assessing the risk for anaphylaxis during this procedure is crucial to prevent any potential harm to the patient. Incorrect choices: A: Administration of the measles-mumps-rubella (MMR) vaccine - While allergic reactions can occur with vaccines, the risk of anaphylaxis with MMR vaccine is lower compared to the contrast solution used in CT scans. B: Rapid administration of intravenous fluids - Rapid IV fluid administration can cause fluid overload or electrolyte imbalances, but it is not typically associated with triggering anaphylaxis. D: Administration of nebulized bronchodil

Correct Answer: C

Rationale: The correct answer is C: Narrative. The nurse is using a narrative interaction by asking the patient to share a personal story. This helps the patient express their experiences, emotions, and perspectives, promoting a deeper understanding of their care needs. A: Nonjudgmental is incorrect as it focuses on avoiding biases. B: Socializing is incorrect as it implies casual conversation. D: SBAR is incorrect as it stands for Situation, Background, Assessment, and Recommendation, used for concise communication in healthcare settings.