foundation of nursing questions and answers

Correct Answer: A

Rationale: The correct answer is A: Abdominal palpation. Palpating the abdomen can potentially cause rupture of the liver in patients with HELLP syndrome due to increased risk of liver hematoma. This can lead to severe bleeding and compromise the patient's condition. Checking deep tendon reflexes (C), auscultation of the heart and lungs (D), and venous sample of blood (B) are safe assessments that do not pose a risk of exacerbating the patient's condition. It is crucial to prioritize patient safety and avoid interventions that can harm the patient, making avoiding abdominal palpation the correct choice in caring for a patient with HELLP syndrome.

Correct Answer: D

Rationale: The correct answer is D: Different molecular structure in the cells. Malignant cells have alterations in their molecular structure, leading to uncontrolled growth and invasion of surrounding tissues, while benign cells retain their normal molecular structure and do not invade nearby tissues. This distinction is crucial in understanding why malignant cells are cancerous and pose a greater risk compared to benign cells. Other choices are incorrect because: A: Slow rate of mitosis of cancer cells - Malignant cells actually have a rapid rate of mitosis, contributing to their uncontrolled growth. B: Different proteins in the cell membrane - While there may be differences in proteins, the molecular structure is a more fundamental difference between malignant and benign cells. C: Differing size of the cells - Cell size alone is not a definitive characteristic that distinguishes between malignant and benign cells; molecular structure plays a more significant role.

Correct Answer: D

Rationale: The correct answer is D. Having emergency equipment readily available is crucial during allergy skin testing as it can lead to severe allergic reactions. This precaution ensures prompt intervention in case of anaphylaxis. Other choices are incorrect because: A) Recent immunizations do not directly impact the skin testing process. B) Administering albuterol is not a standard pre-test requirement. C) Prophylactic epinephrine is not routinely given before allergy skin testing.

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.

Correct Answer: C

Rationale: The correct answer is C: Weight does not change. When a patient's energy requirements are completely met by kcal intake, their weight should remain stable as there is a balance between energy intake and expenditure. This indicates that the body is receiving adequate energy for its needs, leading to weight maintenance. A: Weight increases - This would indicate an excess of energy intake over expenditure, leading to weight gain. B: Weight decreases - This would indicate a deficit in energy intake compared to expenditure, resulting in weight loss. D: Weight fluctuates daily - Daily weight fluctuations are normal and can be influenced by factors like hydration levels, food intake, and exercise, but a stable weight over time indicates a balance between energy intake and expenditure.