foundation of nursing practice questions

Correct Answer: A

Rationale: At present, the most reliable method for verification of placement of small-bore feeding tubes is x-ray examination. X-ray allows for direct visualization of the tube's placement within the gastrointestinal tract, ensuring it is correctly positioned in the stomach without any risk of inadvertent placement in the lungs, pharynx, or esophagus. This method provides a definitive confirmation of tube placement, which is crucial for patient safety during enteral feeding. While pH testing and aspiration of contents can be useful as supplementary methods, x-ray remains the gold standard for verifying tube placement due to its precision and accuracy. Auscultation, on the other hand, is no longer recommended as a reliable method for tube placement verification, as it may lead to misinterpretation of sounds and potential errors in placement assessment.

Correct Answer: D

Rationale: Recurrent episodes of acute otitis media (AOM) can cause fluid accumulation in the middle ear, leading to hearing loss and increased risk of further infections. Insertion of a ventilation tube, also known as a tympanostomy tube, is a common intervention for children with recurrent AOM. This procedure involves placing a tiny tube through the eardrum to allow ventilation and drainage of fluid from the middle ear. Ventilation tubes help equalize pressure, prevent fluid buildup, and reduce the frequency of ear infections. It can improve hearing and decrease the likelihood of future episodes of AOM. Ossiculoplasty, insertion of a cochlear implant, and stapedectomy are not indicated for recurrent AOM.

Correct Answer: D

Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a structured method of communication that healthcare providers use to effectively communicate important information about a patient. The use of SBAR helps ensure that all necessary details are communicated in a clear, concise, and systematic manner, reducing the risk of miscommunication and errors. By standardizing communication using SBAR, nurses can provide a comprehensive report during a shift change, promoting continuity of care and patient safety. Thus, the main rationale for a nurse using SBAR when providing a hands-off report is to standardize communication and improve the quality of patient care.

Correct Answer: A

Rationale: When planning care for an adolescent who plays sports, it is important to provide adequate nutrition to meet their increased energy needs. Carbohydrates are the main source of energy, providing fuel for physical activity. Adolescents engaged in sports require a higher carbohydrate intake and should aim for 55% to 60% of their total daily kilocalories to support their activity levels. Carbohydrates are essential for providing energy during exercise, building and repairing muscles, and promoting overall performance. Increasing carbohydrate intake in the diet is a key modification to support the energy demands of an active adolescent involved in sports.

Correct Answer: C

Rationale: The most appropriate action for the home health nurse to take in this situation where a patient reports distortions when looking at an Amsler grid is to arrange for the patient to be assessed for macular degeneration. Distortions in straight lines on an Amsler grid are a common early symptom of macular degeneration, a progressive eye condition that affects central vision. Macular degeneration is a leading cause of vision loss in older adults, making assessment and early intervention crucial in preserving vision. It is important for the nurse to take the patient's symptoms seriously and facilitate timely evaluation and management to prevent further vision loss. This would involve referring the patient to an ophthalmologist or an eye care specialist for a comprehensive evaluation and appropriate treatment.