foundation of nursing questions

Correct Answer: C

Rationale: The correct answer is C: Keep the patient's bed linens free of wrinkles. This intervention is important in preventing pressure ulcers, a common complication in patients with impaired skin integrity. Wrinkles in bed linens can create pressure points on the skin, leading to skin breakdown. By keeping the bed linens smooth and wrinkle-free, the patient's skin is protected from excessive pressure, reducing the risk of impaired skin integrity. A: Maximizing fluid intake is important for overall health but is not directly related to preventing impaired skin integrity. B: Providing total parenteral nutrition may support the patient's nutritional needs but does not specifically address the risk of impaired skin integrity. D: Providing snug clothing can increase friction and pressure on the skin, potentially worsening the risk of impaired skin integrity.

Correct Answer: B

Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention. Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B. Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B. Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.

Correct Answer: D

Rationale: The correct answer is D - The patient will benefit from a low-protein diet. Patients with Huntington disease often experience difficulty swallowing and may have involuntary movements, leading to weight loss. A low-protein diet can help manage these symptoms and reduce the risk of aspiration pneumonia. This diet can also help control the chorea movements associated with the disease. Choice A is incorrect as patients with Huntington disease often have reduced appetite due to swallowing difficulties. Choice B is incorrect as enzyme supplements are not typically indicated in the management of Huntington disease. Choice C is incorrect as a clear liquid diet is not suitable for meeting the nutritional needs of a patient with Huntington disease, who may already be at risk for malnutrition.

Correct Answer: B

Rationale: Rationale: Assessing breath sounds is crucial in evaluating respiratory status as it helps identify any signs of airway obstruction or respiratory distress. This includes listening for wheezing, crackles, or diminished breath sounds. Lung function testing (A) may not be feasible in an acute emergency situation. Oxygen saturation (C) is important but does not provide a comprehensive assessment of respiratory status. Monitoring respiratory pattern (D) and assessing respiratory rate (E) are important but do not directly assess breath sounds, which are vital in identifying immediate respiratory issues.

Correct Answer: D

Rationale: The correct answer is D: Sentinel node biopsy. This procedure involves identifying and removing the sentinel lymph node(s) which is the first lymph node(s) that cancer cells are likely to spread to from the primary tumor. This method helps determine if cancer has spread beyond the primary site without the need for a full axillary lymph node dissection. It is less invasive, has fewer side effects, and provides accurate staging information. Lymphadenectomy (A) refers to the removal of multiple lymph nodes, which is more extensive than necessary in this case. Needle biopsy (B) and open biopsy (C) are not specific to lymph node evaluation and do not provide accurate staging information for breast cancer.