foundations of nursing test bank

Correct Answer: B

Rationale: The correct answer is B because verifying tube placement before feeding is essential to prevent pulmonary aspiration. If the tube is not correctly positioned in the stomach, there is a risk of feeding going into the lungs. Observing the color of gastric contents (A) may not always indicate correct placement. Adding blue food coloring (C) is unnecessary and could cause confusion. Running the formula over 12 hours (D) does not address the risk of pulmonary aspiration and does not ensure proper tube placement.

Correct Answer: A

Rationale: The correct answer is A because floaters are commonly caused by age-related changes in the vitreous humor of the eye, such as the formation of tiny fibers or clumps. These floaters are typically harmless and not a cause for concern. Choice B is incorrect because glasses do not affect floaters in the eye. Choice C is incorrect because floaters are not a primary symptom of glaucoma. Choice D is incorrect because weakened ciliary muscles are not typically associated with floaters. Therefore, the most appropriate interpretation is that seeing floaters is a normal aging process of the eye.

Correct Answer: B

Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction. Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.

Correct Answer: C

Rationale: The correct answer is C because folic acid is crucial in preventing neural tube defects and anemia in the developing fetus. The nurse should teach the expectant mother about the importance of taking folic acid supplements before and during pregnancy. Folic acid is essential for proper cell division and growth, reducing the risk of birth defects. Choice A is incorrect because calcium intake is important throughout pregnancy, not just in the first trimester. Choice B is incorrect as protein intake should be adequate to support maternal and fetal growth, not decreased. Choice D is incorrect as excessive intake of vitamins and minerals can be harmful to the mother and the baby. In summary, the expectant mother should be educated on the importance of folic acid supplementation to prevent birth defects and anemia, while also ensuring a balanced diet with all essential nutrients.

Correct Answer: B

Rationale: The correct answer is B) Impaired Skin Integrity Related to Kaposis Sarcoma. Kaposis sarcoma can cause skin lesions that may lead to impaired skin integrity due to tissue breakdown. The nurse should prioritize interventions to prevent infection and promote wound healing. Choice A is incorrect because Disuse Syndrome is not directly related to Kaposis Sarcoma. Choice C, Diarrhea, is not a common complication of Kaposis Sarcoma. Choice D, Impaired Swallowing, is not typically associated with Kaposis Sarcoma.