D439 Foundations of Nursing - Set 1 - Part 1

Correct Answer: Ensure airway pressure device

The airway pressure device maintains breathing patterns when sedatives slow respiratory function, preventing complete breathing cessation in sleep apnea patients during recovery.
Option a is incorrect because monitoring alone doesn't prevent respiratory complications; it only detects them after they occur in sedated patients.
Option c is incorrect because upright positioning helps but doesn't address the core breathing interruption issue that sedation worsens.
Option d is incorrect because supplemental oxygen without airway support doesn't prevent the breathing pauses characteristic of sleep apnea.

Correct Answer: Apply padding around tubing

Padding around the cannula tubing cushions pressure points on cheekbones, preventing further skin irritation while maintaining continuous oxygen delivery.
Option a is incorrect because frequent removal interrupts necessary oxygen therapy and doesn't address the pressure causing skin damage.
Option c is incorrect because changing delivery method may not be appropriate for the patient's oxygen needs or comfort level.
Option d is incorrect because flow rate changes don't address the mechanical pressure causing skin breakdown from the tubing.

Correct Answer: Thirty minutes after meals

The gastrocolic reflex naturally stimulates bowel movement thirty minutes after eating, making this timing optimal for establishing regular bowel patterns.
Option a is incorrect because arbitrary two-hour intervals don't align with natural digestive reflexes that promote successful bowel movements.
Option c is incorrect because morning medication timing doesn't correlate with digestive patterns that facilitate bowel training success.
Option d is incorrect because medication schedules vary and don't necessarily coincide with optimal digestive reflex timing for elimination.

Correct Answer: Enter as late entry

Late entry allows proper documentation once the system recovers, maintaining legal requirements and continuity of the medical record accurately.
Option a is incorrect because waiting delays critical documentation that must occur as close to care delivery as possible.
Option b is incorrect because while IT needs notification, the immediate priority is ensuring documentation continuity for patient safety.
Option d is incorrect because paper documentation creates potential transcription errors and may not integrate properly with electronic records.

Correct Answer: Let physician know status

The physician must be informed first about status changes to ensure appropriate care decisions align with the DNR order.
Option a is incorrect because comfort measures follow physician notification and orders regarding the patient's changing condition and care plan.
Option c is incorrect because documentation is important but follows the priority of physician notification for medical decision-making.
Option d is incorrect because family notification typically occurs after medical team communication and assessment of the situation's implications.

Correct Answer: Risk for impaired skin

Decreased sensation from numbness and tingling reduces awareness of pressure or injury, significantly increasing risk for undetected skin breakdown.
Option a is incorrect because mobility issues are secondary to the primary sensory deficit that threatens skin integrity directly.
Option c is incorrect because numbness and tingling indicate neurological issues rather than primary circulation problems requiring different interventions.
Option d is incorrect because while falls are concerning, the immediate risk is undetected skin damage from decreased protective sensation.

Correct Answer: Skin and mucous membranes

Observing skin and mucous membrane color changes provides immediate indicators of oxygenation status and developing respiratory distress during suctioning.
Option a is incorrect because pressure readings indicate equipment function but don't directly reflect the patient's respiratory status changes.
Option c is incorrect because secretion amount doesn't indicate whether the patient is tolerating the procedure or experiencing distress.
Option d is incorrect because comfort indicators are subjective and less reliable than objective signs of respiratory compromise visible externally.

Correct Answer: Stop feed and suction

Immediately stopping the feed prevents additional content entering the stomach while suctioning clears the airway of aspirated material.
Option a is incorrect because notification delays critical interventions needed to clear the airway and prevent further aspiration immediately.
Option c is incorrect because elevation without stopping feed first allows continued filling of an already compromised stomach.
Option d is incorrect because checking placement wastes critical time when immediate cessation and airway clearance are priorities.

Correct Answer: Hold earlobe up back

Pulling the adult earlobe up and back straightens the S-shaped ear canal, allowing medication to flow properly.
Option a is incorrect because down and back positioning is the correct technique for children, not adults with different anatomy.
Option c is incorrect because lateral pulling doesn't adequately straighten the curved adult ear canal for proper medication flow.
Option d is incorrect because forward and down movement constricts rather than opens the ear canal, preventing medication delivery.

Correct Answer: Keep mucous membranes moist

Maintaining moist mucous membranes with ice chips, lip balm, or sprays provides comfort without forcing unwanted intake.
Option a is incorrect because pushing supplements contradicts patient autonomy and may cause distress in terminal care situations.
Option c is incorrect because documentation is less important than comfort measures when a terminal patient chooses intake refusal.
Option d is incorrect because offering high calorie options ignores the patient's expressed wishes and comfort care priorities.

Correct Answer: Start with next void

Beginning collection with the next void ensures a complete twenty-four hour period starting from a known empty bladder baseline.
Option b is incorrect because waiting until morning unnecessarily delays testing and doesn't improve collection accuracy or completeness.
Option c is incorrect because retroactive collection is impossible and would provide inaccurate results missing the initial urine sample.
Option d is incorrect because starting immediately without a voiding baseline leads to inaccurate results from incomplete bladder emptying.

Correct Answer: Bearing weight on palms

Weight bearing through palms prevents nerve damage in armpits while providing stable support during crutch walking safely.
Option a is incorrect because armpit weight bearing compresses nerves and blood vessels, causing numbness and potential permanent damage.
Option c is incorrect because leaning forward shifts center of gravity dangerously, increasing fall risk during crutch ambulation.
Option d is incorrect because large steps compromise balance and control, creating unsafe conditions for non-weight bearing ambulation.

Correct Answer: Have patient demonstrate procedures

Demonstration transcends language barriers by showing actual understanding through actions rather than relying on verbal confirmation alone.
Option a is incorrect because yes or no responses don't verify comprehension and patients may agree without truly understanding.
Option c is incorrect because translation verification after the fact doesn't ensure the original teaching was understood properly.
Option d is incorrect because written materials alone cannot confirm understanding, especially with potential literacy or language barriers.

Correct Answer: Following least restrictive interventions

Restraints are last resort requiring documentation that less restrictive measures like verbal de-escalation failed before physical restraints.
Option a is incorrect because immediate restraint application violates patient rights and regulatory requirements for progressive intervention attempts.
Option b is incorrect because while orders are needed, attempting less restrictive measures must occur first before restraint consideration.
Option d is incorrect because family consent isn't required for emergency restraints when patient poses immediate danger to self or others.

Correct Answer: Show them right way

Direct demonstration of proper technique including between fingers provides immediate correction and education promoting better infection control.
Option a is incorrect because supervisor reporting for technique errors should follow direct peer education and correction attempts first.
Option c is incorrect because formal documentation isn't necessary for minor technique issues that can be corrected through colleague education.
Option d is incorrect because ignoring improper hand hygiene techniques compromises infection control and patient safety standards significantly.

Correct Answer: Antibiotics are not working

Rising white blood cell counts during antibiotic treatment indicates the current antibiotics aren't effectively controlling the resistant infection.
Option a is incorrect because healing would show decreasing, not increasing, white blood cell counts as infection resolves successfully.
Option c is incorrect because while possible, increasing white cells specifically indicates treatment failure before assuming systemic progression.
Option d is incorrect because assuming laboratory error without clinical correlation delays necessary treatment modifications for resistant infections.

Correct Answer: Do not return call

High residual volumes over five hundred milliliters indicate delayed gastric emptying requiring physician notification before proceeding safely.
Option a is incorrect because returning large residuals and feeding risks aspiration from overfilled stomach and poor gastric motility.
Option b is incorrect because partial discard doesn't address the underlying gastric emptying problem requiring medical evaluation immediately.
Option d is incorrect because dilution doesn't resolve high residual volumes and may worsen gastric distention causing aspiration risk.

Correct Answer: Side-lying position for drainage

Side-lying position allows gravity drainage of fluids away from the airway, preventing pooling and aspiration during oral care.
Option a is incorrect because supine positioning even with elevation allows fluid accumulation in the posterior pharynx risking aspiration.
Option c is incorrect because upright positioning in unconscious patients is unstable and doesn't facilitate lateral fluid drainage.
Option d is incorrect because Trendelenburg position increases aspiration risk by promoting fluid movement toward the airway and lungs.

Correct Answer: Wound edges well approximated

Well approximated edges indicate proper surgical closure alignment allowing healing by primary intention without gaps or separation.
Option b is incorrect because while some drainage is normal, it doesn't specifically indicate proper primary intention healing progression.
Option c is incorrect because redness may indicate inflammation or infection rather than normal uncomplicated healing by primary intention.
Option d is incorrect because visible granulation tissue suggests healing by secondary intention, not the expected primary intention.

Correct Answer: Blister on skin surface

Stage two pressure ulcers characteristically present with blisters or shallow open wounds affecting epidermis and dermis layers.
Option a is incorrect because intact red skin indicates stage one pressure ulcer without the skin breakdown of stage two.
Option c is incorrect because visible subcutaneous fat indicates deeper stage three pressure ulcer with full thickness skin loss.
Option d is incorrect because visible muscle tissue indicates stage four pressure ulcer with extensive deep tissue damage present.