foundations of nursing practice questions

Correct Answer: B

Rationale: The correct answer is B because an incomplete abortion at 16 weeks may require a D&C to remove remaining tissue to prevent infection and complications. Incomplete abortion means not all fetal tissue has been expelled, posing a risk. Choice A (complete abortion at 8 weeks) does not require a D&C as all tissue is expelled. Choice C (threatened abortion at 6 weeks) does not necessitate immediate intervention. Choice D (incomplete abortion at 10 weeks) is not the best choice as the risk of complications increases with gestational age.

Correct Answer: A

Rationale: Correct Answer: A Rationale: Abdominal cramping in a patient on enteral feedings could indicate feeding intolerance. The nurse's initial action should be to slow down the rate of the tube feeding to allow the patient's gastrointestinal tract to adjust gradually. This helps reduce the risk of further complications and allows for better tolerance. Slowing the rate is a safe and effective intervention that can help alleviate the abdominal cramping without causing additional stress on the patient's digestive system. Summary of Incorrect Choices: B: Instilling cold formula is not a recommended practice and can potentially cause harm or discomfort to the patient. C: Changing to a high-fat formula may exacerbate the abdominal cramping as it can be harder to digest for some patients. D: Consulting with the healthcare provider about prokinetic medication should come after trying less invasive interventions such as slowing the rate of tube feeding.

Correct Answer: B

Rationale: The correct answer is B: In a flat side-lying position. Rationale: 1. A flat side-lying position helps reduce pressure on the surgical site, promoting comfort and preventing injury. 2. This position minimizes strain on the spine and supports proper alignment. 3. High Fowlers position may increase pressure on the surgical area due to increased intra-abdominal pressure. 4. Trendelenberg position and reverse Trendelenberg position are not appropriate for spine surgery patients as they can cause increased blood flow to the surgical site, leading to potential complications.

Correct Answer: A

Rationale: The correct answer is A: Leukopenia. Taxol and Paraplatin are known to cause bone marrow suppression, leading to decreased white blood cell counts. Leukopenia can increase the patient's risk of infection, so monitoring for signs of infection is crucial. Metabolic acidosis, hyperphosphatemia, and respiratory alkalosis are not typically associated with Taxol and Paraplatin chemotherapy.

Correct Answer: C

Rationale: The correct answer is C: Risk for falls. Patients with vertigo experience a false sensation of spinning or movement, which can lead to imbalance and increased risk of falls. Prioritizing the risk for falls is crucial to prevent injuries and ensure patient safety. Other choices are incorrect as they do not directly address the immediate safety concern of falls associated with vertigo. A: Risk for disturbed sensory perception may be present, but the priority is preventing falls. B: Risk for unilateral neglect is not typically associated with vertigo. D: Risk for ineffective health maintenance is important but falls take precedence due to the immediate risk of injury.