foundation of nursing practice questions

Correct Answer: D

Rationale: When caring for a patient receiving total parenteral nutrition (TPN), it is crucial to maintain strict aseptic technique to prevent infection. Wearing a sterile mask when changing the central venous catheter dressing helps to reduce the risk of introducing pathogens into the catheter site, which can lead to serious bloodstream infections. It is essential to use sterile gloves, a sterile mask, and to assess the insertion site for any signs or symptoms of infection during central venous catheter dressing changes. Additionally, to prevent infection, TPN infusion tubing should be changed every 24 hours, and no single container of TPN should be hung for longer than 24 hours, with lipids not running for longer than 12 hours.

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: A

Rationale: The nurse's best response should be to provide accurate information and manage the patient's expectations realistically. Tamoxifen is known to have a slight protective effect in reducing the risk of developing breast cancer in high-risk individuals like the patient in the scenario. However, it is not a guarantee against developing breast cancer. It is essential for the nurse to convey this information to the patient to ensure that she understands the benefits and limitations of Tamoxifen therapy. Additionally, discussing potential side effects and risks associated with Tamoxifen, such as an increased risk of osteoporosis, is important for the patient to make an informed decision about her health care.

Correct Answer: A

Rationale: The statement "If I get a blue color that means the test is negative" given by the patient indicates the need for further education. This is incorrect information because a blue color in the guaiac test indicates a positive result, which means the presence of fecal occult blood. The patient should be taught that a positive result indicates the need for further evaluation and follow-up with their healthcare provider. Proper understanding of the test results is vital to ensure accurate interpretation and appropriate management. Further clarification and education are necessary to correct this misconception and guide the patient towards understanding the significance of a positive result.

Correct Answer: A

Rationale: Encouraging the patient to verbalize her questions and concerns is the best way to assess her specific educational, physical, or psychosocial needs during preoperative teaching for an incisional biopsy of a right breast mass. This approach allows the nurse to better understand the patient's knowledge level, fears, anxieties, and any misconceptions she may have related to the procedure. By actively listening to the patient's questions and concerns, the nurse can tailor the education provided to address specific areas of importance to the patient, ensuring she receives the information and support she needs to feel prepared and comfortable before the procedure. This approach promotes open communication, trust, and patient-centered care.