foundation of nursing practice questions

Correct Answer: A

Rationale: When obtaining a 24-hour urine specimen, it is important to keep the urine collection container on ice if indicated. Storing the urine on ice helps to preserve the integrity of certain components in the specimen that might be affected by higher temperatures. Some tests require the sample to be kept cool to ensure accurate results. Therefore, the nurse should follow the specific instructions provided for the collection and storage of the urine specimen.

Correct Answer: D

Rationale: The patient in this scenario exhibits signs of chronic hypertension, particularly due to the history of heart disease in her family, the postpartum persistence of elevated blood pressure, and the diagnosis of hypertension at the 6-week checkup. While pregnancy-induced hypertension (PIH), gestational hypertension, and preeclampsia can occur during pregnancy, they typically resolve within a few weeks after delivery. The fact that the patient's hypertension persists beyond the postpartum period suggests that she likely had preexisting, undiagnosed chronic hypertension. Therefore, option D is the most appropriate choice in this case.

Correct Answer: B

Rationale: When admitting a pregnant patient who has experienced a bleeding episode in late pregnancy, the top priority nursing intervention is to assess fetal heart rate (FHR) and maternal vital signs. This assessment will help the nurse determine the extent of the blood loss and its impact on both the mother and the fetus. Monitoring uterine contractions is important as well, but not the priority in this situation. Placing clean disposable pads to collect any drainage is important for ongoing assessment and management but can be done after assessing the FHR and vital signs. Performing a venipuncture for hemoglobin and hematocrit levels is necessary for further evaluation but can be done after the initial assessment of FHR and vital signs. Checking the patient and fetal well-being is crucial in situations of bleeding in late pregnancy to ensure timely and appropriate intervention.

Correct Answer: D

Rationale: Blurred vision is a common adverse effect of pilocarpine, a miotic agent commonly used for open-angle glaucoma. It occurs due to the constriction of the pupil, which can affect the patient's ability to focus clearly. Therefore, it is important for the nurse to explain to the patient that blurred vision is an expected adverse effect of the medication. This reassurance can help alleviate the patient's concerns and improve their understanding of the medication therapy. Holding the next dose and notifying the physician is not necessary in this situation as blurred vision is a known side effect and treating the patient for an allergic reaction or suggesting that the patient put on her glasses would not address the underlying cause of the blurred vision.

Correct Answer: B

Rationale: The patient's frustration with chronic nasal congestion, anosmia, and inability to concentrate indicates difficulty coping with the long-term nature of her condition and the impact it has on her daily life. Additionally, her desire for relief suggests a need for environmental modifications to help manage her symptoms. This nursing diagnosis encompasses the patient's emotional response to her condition, as well as the potential need for changes in her surroundings to better support her health and well-being.