foundations of nursing practice questions

Correct Answer: B

Rationale: The correct answer is B: Impaired wound healing. Radiation therapy can lead to damage to the skin and blood vessels, affecting wound healing. The nurse should prioritize assessing the patient's skin integrity and any signs of impaired wound healing to prevent complications post-surgery. A: Cognitive deficits - While radiation therapy can impact cognitive function in some cases, it is not the most immediate concern related to surgery post-radiation therapy. C: Cardiac tamponade - Although radiation therapy can increase the risk of heart-related issues, such as pericarditis, cardiac tamponade is a rare and acute complication that is not the most likely immediate concern post-radiation therapy. D: Tumor lysis syndrome - This syndrome is more commonly seen in patients undergoing chemotherapy rather than radiation therapy. It is not typically a concern immediately post-radiation therapy.

Correct Answer: A

Rationale: The correct answer is A because an ultrasound-guided core biopsy is indeed faster, less expensive, and does not use radiation. - "Faster": Ultrasound-guided biopsies are typically quicker compared to stereotactic biopsies, as they are performed in real-time using ultrasound imaging. - "Less expensive": Ultrasound-guided biopsies are generally more cost-effective than stereotactic biopsies due to the equipment and resources required. - "Does not use radiation": Unlike stereotactic biopsies which involve the use of X-rays for guidance, ultrasound-guided biopsies do not expose the patient to radiation, making them safer in that aspect. The other choices are incorrect because they either inaccurately state that ultrasound-guided biopsies use radiation (C), take more time (D), or imply a slight increase in cost without highlighting the key advantages of speed and lack of radiation (B).

Correct Answer: A

Rationale: The correct answer is A: Red wine colored. Following a prostatectomy, continuous bladder irrigation is commonly used to prevent blood clots and ensure urine drainage. The output is expected to be red wine colored, indicating the presence of blood in the urine due to surgical trauma. Tea-colored (choice B) or amber (choice C) are not specific enough and do not accurately reflect the expected bloody output. Light pink (choice D) may suggest a lower level of bleeding compared to red wine color, but it is not the most accurate description for post-prostatectomy drainage.

Correct Answer: B

Rationale: The correct answer is B: Nonverbal. The patient used nonverbal communication by pointing to the area of pain, which is a form of expressing information without words. This choice is correct because pointing is a nonverbal gesture that conveys a specific message. Verbal communication (A) involves spoken or written words, which were not used in this scenario. Intonation (C) refers to the rise and fall of the voice in speech, which was not demonstrated by the patient. Vocabulary (D) is the range of words known or used by a person, but the patient did not use words to communicate in this situation. In summary, the patient used nonverbal communication through pointing, making choice B the correct answer.

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.