foundation of nursing practice questions

Correct Answer: B

Rationale: The signs of magnesium toxicity that the nurse should monitor for in a patient with severe preeclampsia on IV magnesium sulfate include an altered sensorium (confusion, lethargy, slurred speech) and a respiratory rate of less than 12 breaths per minute. Altered sensorium is a common symptom of magnesium toxicity, reflecting the drug's central nervous system depressant effects. A decreased respiratory rate can indicate respiratory depression, a potentially serious complication of magnesium toxicity. Monitoring for these signs is crucial to promptly identifying and managing magnesium toxicity in patients on magnesium sulfate therapy. Signs such as cool, clammy skin and a pulse oximeter reading of 95% would not be indicative of magnesium toxicity.

Correct Answer: A

Rationale: Patients diagnosed with Parkinson's disease often experience speech and communication difficulties due to the effects of the disease on the muscles involved in speech production. This can manifest as soft, slurred speech or difficulty articulating words. Therefore, promoting effective communication would be an essential goal in the plan of care for a patient with Parkinson's disease. This goal may involve strategies such as speech therapy, communication devices, or providing a conducive environment to facilitate clearer communication between the patient and healthcare providers. By focusing on promoting effective communication, the nurse can help improve the patient's quality of life and enhance their ability to express their needs and concerns.

Correct Answer: C

Rationale: Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. A key intervention to prevent catheter-associated urinary tract infections is prevention of urine back flow from the tubing and bag into the bladder. All the other actions are correct procedures and do not require immediate follow-up. The drainage bag should be emptied when it is half full to prevent tension and pulling on the catheter, which could result in trauma to the urethra and increase the risk for urinary tract infections. Urine specimens are traditionally obtained by temporarily kinking the tubing, while securing the catheter tubing to the patient�s thigh prevents catheter dislodgment and tissue injury.

Correct Answer: B

Rationale: The most appropriate action for the nurse to take in this situation is to apply warm compresses to the patient's lower abdomen. Abdominal bloating and an increase in abdominal girth can be common following a vaginal hysterectomy. Applying warm compresses to the lower abdomen can help to relieve bloating and discomfort by promoting relaxation of the abdominal muscles and increasing blood flow to the area. This can provide relief to the patient and support their recovery process. Applying warm compresses is a non-invasive intervention that can be easily implemented and is commonly used in post-operative care to address abdominal discomfort.

Correct Answer: A

Rationale: The best time for a nurse to start discharge planning for a patient admitted with pneumonia and a congested cough is upon admission. Starting discharge planning early allows the healthcare team to identify the patient's needs, plan for the appropriate level of care, and ensure a smooth transition out of the hospital. Waiting until right before discharge or after the congestion is treated may lead to rushed or incomplete planning, potentially compromising the patient's recovery and post-discharge care. Additionally, discharge planning is not dependent on the primary care provider writing an order, as nurses can initiate teaching and planning proactively to support the patient's optimal recovery and transition. By beginning discharge planning upon admission, the healthcare team can address any potential barriers to discharge and ensure the patient's needs are met for a successful recovery process.