foundation of nursing questions and answers

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foundation of nursing questions and answers Questions

Question 1 of 5

The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the patients plan of care?

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Exostoses are bony growths in the external auditory canal. 2. These growths can cause narrowing and obstruction of the canal, affecting hearing. 3. Collaborating with the pharmacist to assess for ototoxic medications is crucial to prevent further hearing impairment. 4. Performing Rinne and Weber tests (choice A) and arranging audiometry testing (choice B) are not directly related to exostoses. 5. Ignoring exostoses (choice D) can lead to worsening hearing loss and potential complications.

Question 2 of 5

When assessing patient with nutritional needs, which patients will require follow-up from the nurse?(Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A: A patient with infection taking tetracycline with milk. This is because tetracycline binds with the calcium in milk, reducing its absorption and effectiveness. The nurse should follow up to ensure the patient is not compromising the treatment. Choices B and C are incorrect because increasing fiber for irritable bowel syndrome and following a high-fiber diet for diverticulitis are appropriate interventions that do not require immediate follow-up. Choice D is incorrect because it is a routine part of managing enteral feedings to monitor gastric residuals, and does not necessarily require immediate follow-up unless there are specific concerns.

Question 3 of 5

The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse�s next action?

Correct Answer: D

Rationale: The correct answer is D: Use electronic fetal surveillance to determine a baseline fetal heart rate. This is important in assessing the well-being of the fetus during labor, especially in the presence of genital herpes lesions. Monitoring the fetal heart rate helps in detecting any signs of distress or compromise due to maternal infection. A: Asking about the patient's last intake is important but not the immediate priority when managing a patient with active genital herpes lesions in labor. B: Taking a culture of the lesions might be helpful but not the immediate action needed in this situation. C: Asking about unprotected sex is relevant but not as critical as monitoring the fetal well-being during labor in this scenario. Overall, the most critical action is to monitor the fetal heart rate for any signs of distress related to the maternal herpes infection.

Question 4 of 5

During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?

Correct Answer: D

Rationale: The correct answer is D: Pneumocystis pneumonia. This is the most common life-threatening infection in HIV-positive patients with low CD4+ counts. Pneumocystis pneumonia is caused by the opportunistic pathogen Pneumocystis jirovecii, which can lead to severe respiratory distress and mortality in immunocompromised individuals. The other choices, A: Salmonella infection, B: Mycobacterium tuberculosis, and C: Clostridium difficile, can also cause infections in HIV-positive patients, but they are not as commonly associated with life-threatening complications in this population compared to Pneumocystis pneumonia. It is crucial for the nurse to prioritize assessment for signs and symptoms of Pneumocystis pneumonia in this patient to promptly intervene and prevent further complications.

Question 5 of 5

A nurse is preparing a bowel training programfor a patient. Which actions will the nurse take? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A. Recording times when the patient is incontinent is crucial in identifying patterns and establishing a structured bowel training program. This data helps in determining the optimal timing for toileting. Choices B, C, and D are incorrect. Choice B is not specific to bowel training and may not address the patient's individual needs. Choice C is not a recommended posture for effective bowel elimination. Choice D, while important for overall health, is not directly related to bowel training.

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