foundation of nursing practice questions

Correct Answer: C

Rationale: In this scenario, the patient who has had a cervical diskectomy is experiencing severe pain with a sudden onset, which can be indicative of a complication such as bleeding, infection, or nerve impingement. The nurse's most appropriate action is to call the surgeon immediately to report the patient's pain. The surgeon needs to be informed promptly so that a further assessment can be made and appropriate interventions can be initiated to address the cause of the sudden pain. Palpating the surgical site or removing the dressing without consulting the surgeon first may worsen the situation or increase the risk of complications. Administering an NSAID is not appropriate in this situation without further evaluation and guidance from the surgeon. It is essential to prioritize patient safety and ensure that the patient receives timely and appropriate care by involving the surgeon in the decision-making process.

Correct Answer: D

Rationale: Recurrent episodes of acute otitis media (AOM) can cause fluid accumulation in the middle ear, leading to hearing loss and increased risk of further infections. Insertion of a ventilation tube, also known as a tympanostomy tube, is a common intervention for children with recurrent AOM. This procedure involves placing a tiny tube through the eardrum to allow ventilation and drainage of fluid from the middle ear. Ventilation tubes help equalize pressure, prevent fluid buildup, and reduce the frequency of ear infections. It can improve hearing and decrease the likelihood of future episodes of AOM. Ossiculoplasty, insertion of a cochlear implant, and stapedectomy are not indicated for recurrent AOM.

Correct Answer: D

Rationale: Mashed potatoes and gravy are not appropriate for a full liquid diet. A full liquid diet consists of foods that are liquid at room temperature or melt into liquid form at body temperature. Mashed potatoes and gravy are not in liquid form and therefore should not be consumed by a patient following a full liquid diet. The nurse should intervene and provide education about the correct food choices allowed on a full liquid diet, such as custard, frozen yogurt, and pureed vegetables.

Correct Answer: D

Rationale: Black or tarry stools can be caused by certain medications and supplements, such as iron supplements. Since the fecal occult test is negative, it indicates that bleeding is not occurring. Therefore, in this situation, it is important to consider factors that can affect the color of stool, including iron supplementation. Addressing this question can help determine the cause of the black stool and provide appropriate guidance or reassurance to the patient. This response shows a comprehensive understanding of potential causes and demonstrates a thoughtful approach in addressing the patient's concern.

Correct Answer: D

Rationale: In communication, feedback is the response or message provided by the receiver to the sender. In this scenario, the nurse asks the patient, "How are you doing?" The patient's response, "I don't feel good," is the feedback. It is the patient's reaction and message returning to the nurse. The nurse, in this context, is the sender initiating the conversation, while the patient is the receiver providing the feedback in response to the nurse's inquiry. Therefore, the statement "I don't feel good" constitutes the feedback in this communication exchange.