foundation of nursing practice questions

Correct Answer: B

Rationale: The most appropriate action for the nurse to take when observing the surgical dressing saturated with serosanguineous drainage is to reinforce the dressing and reassess in 1 to 2 hours. Serosanguineous discharge is a common type of drainage following surgery, as it is a mixture of blood and serum. It is expected in the early stages of wound healing and does not necessarily indicate infection. By reinforcing the dressing and closely monitoring the drainage over the next couple of hours, the nurse can assess if the amount of drainage is decreasing or escalating. If there are any signs of infection, such as increasing redness, warmth, swelling, or excessive purulent discharge, then the nurse should notify the physician promptly. Until then, it is appropriate to continue observing and managing the drainage within the expected range.

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: D

Rationale: The correct sequence for drawing up a prescribed amount of sterile solution ordered is as follows: 6, 5, 1, 3, 2, 4.

Correct Answer: B

Rationale: Smoking cessation most directly addresses the leading cause of cancer deaths in North America, which is lung cancer. Tobacco use, particularly cigarette smoking, is the primary cause of lung cancer. By helping individuals quit smoking, the public health nurse is targeting the main risk factor for lung cancer and therefore addressing the root cause of the issue. This intervention has the potential to have a significant impact on reducing cancer-related deaths in the community. Monthly self-breast exams, annual colonoscopies, and monthly testicular exams are important for detecting breast, colon, and testicular cancers respectively, but they do not directly address the leading cause of cancer deaths in North America.

Correct Answer: C

Rationale: The most appropriate action for the home health nurse to take in this situation where a patient reports distortions when looking at an Amsler grid is to arrange for the patient to be assessed for macular degeneration. Distortions in straight lines on an Amsler grid are a common early symptom of macular degeneration, a progressive eye condition that affects central vision. Macular degeneration is a leading cause of vision loss in older adults, making assessment and early intervention crucial in preserving vision. It is important for the nurse to take the patient's symptoms seriously and facilitate timely evaluation and management to prevent further vision loss. This would involve referring the patient to an ophthalmologist or an eye care specialist for a comprehensive evaluation and appropriate treatment.