foundation of nursing questions and answers

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: C

Rationale: The correct answer is C: Ascending. Stool consistency varies based on the location of the ostomy. The ascending colon is responsible for absorbing water from stool, so an ostomy in this location will have very liquid stool. Sigmoid, transverse, and descending colons are responsible for further solidifying stool, so ostomies in those locations would not typically have very liquid stool.

Correct Answer: A

Rationale: The correct answer is A: Not until the drain is removed. After a mastectomy with immediate reconstruction, there is typically a drain in place to collect fluid. Showering before the drain is removed can increase the risk of infection and disrupt the healing process. It is important to wait until the healthcare provider removes the drain to ensure proper healing and reduce the risk of complications. Summary: B: On the second postoperative day - Too early, the drain needs to be removed first. C: Now, if you wash gently with soap and water - Incorrect, the drain should be removed before showering. D: Seven days after your surgery - Incorrect, waiting for a specific number of days is not necessary, it depends on when the drain is removed.

Correct Answer: B

Rationale: The correct answer is B: Uterine infection. The patient's symptoms of crampy abdominal pain, scant serosanguineous vaginal drainage with odor, negative pregnancy test, and vital signs indicating fever, low blood pressure, and irregular pulse suggest an infection. The history of recent miscarriage raises suspicion for retained products of conception leading to infection. Ectopic pregnancy (choice A) would present with different symptoms such as abdominal pain, vaginal bleeding, and positive pregnancy test. Gestational trophoblastic disease (choice C) typically presents with abnormal vaginal bleeding and high levels of hCG. Endometriosis (choice D) is a chronic condition and not related to the acute symptoms described. In summary, the clinical presentation aligns with uterine infection given the patient's history, symptoms, and vital signs.

Correct Answer: C

Rationale: The correct answer is C: indirect Coombs test of the mother. This test is crucial to determine if the mother has developed antibodies against the Rh-positive blood of twin A, which could lead to hemolytic disease of the newborn in future pregnancies. A direct Coombs test of twin A or twin B is not relevant in this scenario as it does not provide information about the mother's antibody status. Transcutaneous bilirubin levels are used to monitor jaundice in newborns and not related to Rh incompatibility. In summary, the indirect Coombs test of the mother is the most relevant test to assess the risk of hemolytic disease in future pregnancies.