foundation of nursing practice questions

Correct Answer: A

Rationale: Swelling and pain at the IV site can indicate extravasation, which is the leakage of a vesicant medication like doxorubicin hydrochloride into the surrounding tissues. It is crucial to stop the administration of the drug immediately upon suspicion of extravasation to minimize tissue damage and potential complications. By stopping the administration promptly, further harm can be prevented, and early interventions can be initiated to mitigate the effects of the extravasation. Notifications to the physician and appropriate actions, such as aspiration of any remaining drug, may follow after discontinuing the infusion.

Correct Answer: B

Rationale: During the primary infection stage of HIV, the patient is newly infected with the virus. At this stage, the patient's immune system has not yet produced HIV-specific antibodies, making it difficult to detect HIV infection using standard antibody tests. Instead, the virus can be detected by testing for the presence of HIV RNA or p24 antigen. The primary infection stage is characterized by a high level of viral replication and rapid spread of the virus throughout the body. In this early stage, the patient may experience flu-like symptoms such as fever, sore throat, muscle aches, and swollen lymph nodes. The absence of HIV-specific antibodies means that the patient is highly infectious and can easily transmit the virus to others. As the infection progresses, the patient will eventually develop HIV-specific antibodies, which can be detected through antibody tests.

Correct Answer: B

Rationale: The nurse should prioritize educating the patient on the importance of keeping appointments for desensitization procedures. Immunotherapy involves gradually increasing exposure to allergens to build tolerance and reduce allergic reactions. Missing desensitization appointments can lead to interruptions in treatment and potentially decrease the effectiveness of the therapy. It is crucial for the patient to adhere to the scheduled appointments as prescribed by the healthcare provider to ensure the success of the immunotherapy treatment.

Correct Answer: A

Rationale: In the assessment of a patient with potential placenta previa or abruptio placentae, the nurse should pay close attention to the amount and characteristics of vaginal bleeding. Placenta previa typically presents with painless vaginal bleeding, which can be sudden and significant. Therefore, a saturated perineal pad within a short period of time (1 hour) is more indicative of placenta previa, as opposed to abruptio placentae which usually presents with painful vaginal bleeding and may not necessarily saturate a perineal pad quickly. Monitoring the amount of bleeding and keeping track of pad saturation over time can provide valuable information to differentiate between these two conditions.

Correct Answer: C

Rationale: Patients with Meniere's disease are often advised to limit their intake of salt as excess salt can worsen symptoms such as dizziness and vertigo. Shellfish tend to be high in sodium, so patients with Meniere's disease should be instructed to avoid or limit their consumption of shellfish to help manage their condition. It is important for the nurse to provide comprehensive diet education to the patient to help them minimize symptoms and improve their overall quality of life.