foundation of nursing questions and answers

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Ambulating is a crucial postoperative activity to prevent complications like blood clots. 2. Understanding when to ambulate ensures the patient follows proper recovery guidelines. 3. Proper ambulation aids in preventing postoperative complications and promotes healing. Summary of why other choices are incorrect: B. Having someone accompany the patient is important for support but not a strict criteria for discharge. C. While understanding activity restrictions is important, it is not a specific criteria for immediate discharge. D. Understanding care for the biopsy site is essential but not a strict criteria for immediate discharge. E. Removal of a urinary catheter is not typically related to discharge criteria for a breast biopsy.

Correct Answer: C

Rationale: The correct answer is C: Increase the patient's oral fluid intake. This is because severe diarrhea can lead to dehydration, which can be dangerous for patients with HIV infection. By increasing oral fluid intake, the patient can stay hydrated and prevent further complications. Administering antidiarrheal medications on a scheduled basis (Choice A) may provide temporary relief but does not address the underlying issue of dehydration. Encouraging the patient to eat balanced meals (Choice B) and increase activity level (Choice D) may be important for overall health but do not directly address the immediate concern of dehydration caused by severe diarrhea.

Correct Answer: D

Rationale: The correct answer is D. The goal of nursing interventions in this scenario is to teach family members how to interact with and ensure safety for the patient with impaired cognition. This is the most appropriate response because it addresses the immediate need to provide the patient with appropriate care and support in their home environment. By educating the family on how to interact with the patient and ensure their safety, the nurse can help maintain a sense of normalcy for the patient and promote their well-being. Choice A is incorrect because sedating the patient may not be the best approach without considering other interventions first. Choice B is incorrect as moving the patient to an acute-care facility may not be necessary or feasible at this time. Choice C is incorrect as it focuses on end-of-life care rather than addressing the immediate need of supporting the patient with altered mental status.

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: B

Rationale: The correct answer is B: Labeling all specimens with date, time, and initials. This is important for proper identification and tracking of the specimen. - Choice A is incorrect because urine cultures typically take longer than 12 hours to grow. - Choice C is incorrect as privacy is important but not a specific action related to urine specimen collection. - Choice D is incorrect as wearing gown, gloves, and mask may not be necessary for routine urine specimen collection, unless there are specific precautions needed.