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: "Don't blow your nose for 2 to 3 weeks." After mastoid surgery, blowing the nose can increase pressure in the surgical area and disrupt healing. Here's the rationale: 1. Blowing the nose can increase pressure in the surgical area and lead to complications. 2. Avoiding blowing the nose helps prevent infection and reduces the risk of damaging the surgical site. 3. It is essential to follow this instruction to promote proper healing and reduce the chances of postoperative complications. In summary, the other choices are incorrect because inducing a sneeze, exercising, and avoiding side-lying position do not directly relate to the specific care needs after mastoid surgery.

Correct Answer: C

Rationale: The correct answer is C because reviewing current medications with a pharmacist is crucial in understanding potential threats to vision. Some medications can have side effects that impact eye health. This proactive approach shows an understanding of how medication can affect vision. Choice A is incorrect because while avoiding direct sunlight is important for eye health, it does not address other potential threats. Choice B is incorrect because regular exercise, while beneficial for overall health, does not directly relate to understanding threats to vision. Choice D is incorrect because monitoring blood pressure is important for cardiovascular health but does not specifically address threats to vision.

Correct Answer: B

Rationale: The correct answer is B: Tachypnea and restlessness. This observation takes immediate priority as it indicates potential respiratory distress, a common complication of pneumonia in HIV patients. Tachypnea can be a sign of hypoxia, while restlessness may indicate increased work of breathing. Prompt intervention is crucial to prevent respiratory failure. Choice A: Oral temperature of 100F is not an immediate priority as it is within normal range and may not directly impact the patient's immediate condition. Choice C: Frequent loose stools may suggest gastrointestinal issues but are not as urgent as respiratory distress in this scenario. Choice D: Weight loss of 1 pound since yesterday, while relevant in monitoring the patient's condition, does not require immediate intervention compared to respiratory distress.