D439 Foundations of Nursing - Set 3 - Part 1

Correct Answer: Fluid volume deficit present

Three days of vomiting and diarrhea cause severe dehydration requiring immediate fluid replacement to prevent cardiovascular collapse and shock.
Option a is incorrect because nutritional deficits develop slowly and don't pose the immediate life-threatening risk that dehydration presents acutely.
Option c is incorrect because skin breakdown is a later complication while fluid deficit threatens immediate cardiovascular and organ function.
Option d is incorrect because while electrolyte imbalances occur, fluid volume deficit is the primary immediate threat requiring urgent intervention.

Correct Answer: Notify surgical team members

Surgical team notification ensures anesthesiologist and surgeon understand code status preferences before proceeding with planned surgery requiring immediate communication.
Option a is incorrect because documentation alone doesn't ensure the surgical team knows about critical resuscitation preferences affecting procedure planning.
Option b is incorrect because surgery doesn't automatically require cancellation; team discussion determines appropriate options for the patient's situation.
Option d is incorrect because team notification takes priority over paperwork to ensure everyone understands preferences before surgery proceeds.

Correct Answer: Bilateral clear lung sounds

Clear lung sounds indicate successful fluid removal from pulmonary circulation, demonstrating effective diuresis for fluid volume excess treatment.
Option a is incorrect because weight gain suggests fluid retention rather than successful diuresis removing excess volume as intended therapeutically.
Option c is incorrect because increased edema indicates worsening fluid accumulation, not successful treatment removing excess fluid volume effectively.
Option d is incorrect because elevated pressure suggests continued fluid overload rather than successful volume reduction through diuretic therapy.

Correct Answer: Living will states my wishes

Living wills express personal wishes for medical care when unable to communicate, while power of attorney designates decision-makers.
Option a is incorrect because these documents serve different purposes with living wills expressing wishes and POA naming surrogate decision-makers.
Option c is incorrect because power of attorney doesn't replace living wills; they complement each other for comprehensive advance planning.
Option d is incorrect because living wills state treatment preferences while durable power of attorney specifically names healthcare decision-makers.

Correct Answer: Collect sample and proceed

Collecting stool samples for testing while continuing care allows laboratory analysis to identify bleeding sources requiring treatment intervention.
Option a is incorrect because occult blood is abnormal requiring investigation, not documentation as normal finding without further action taken.
Option c is incorrect because sample collection should occur before notification to provide complete information for medical decision-making effectively.
Option d is incorrect because withholding meals isn't indicated solely for occult blood without physician orders for dietary restrictions.

Correct Answer: Back and forth motions

Back and forth cleansing after foreskin retraction effectively removes contaminants from the meatus while maintaining sterile technique properly.
Option a is incorrect because circular motions risk recontaminating cleaned areas by bringing dirty solution back over clean tissue surfaces.
Option c is incorrect because single strokes provide insufficient cleansing to remove contaminants that could cause catheter-associated urinary infections.
Option d is incorrect because spiral patterns may spread contamination rather than effectively removing it from the urethral opening.

Correct Answer: Skin abrasion from straps

Skin abrasions from CPAP straps indicate pressure injury requiring padding or adjustment to prevent further breakdown while maintaining therapy.
Option a is incorrect because clear breathing sounds indicate effective CPAP therapy without complications requiring intervention or adjustment currently needed.
Option c is incorrect because sound sleep suggests successful sleep apnea treatment with CPAP working effectively without complications present.
Option d is incorrect because decreased snoring indicates proper CPAP function opening airways effectively, not a complication requiring intervention.

Correct Answer: Subcutaneous fat tissue visible

Stage three ulcers involve full thickness skin loss with visible subcutaneous fat but without exposed muscle or bone tissue.
Option a is incorrect because intact reddened skin describes stage one pressure injuries without the tissue loss of stage three.
Option b is incorrect because epidermis and dermis involvement describes stage two ulcers, not the deeper stage three tissue loss.
Option d is incorrect because muscle and bone exposure indicates stage four pressure ulcers with deeper damage than stage three.

Correct Answer: Visualize peaceful calming places

Visualizing peaceful places activates parasympathetic responses reducing anxiety through mental relaxation techniques before procedures requiring calmness for cooperation.
Option a is incorrect because focusing on procedure details typically increases rather than decreases anxiety before medical interventions or procedures.
Option c is incorrect because reviewing complications heightens fear and anxiety rather than promoting the relaxation guided imagery provides therapeutically.
Option d is incorrect because concentrating on pain anticipation increases anxiety rather than using positive imagery for relaxation benefits.

Correct Answer: Risk for skin integrity impairment

Numbness reduces protective sensation awareness making patients unable to detect pressure or injury leading to skin breakdown.
Option a is incorrect because activity intolerance relates to endurance issues rather than the sensory deficits numbness creates for patients.
Option c is incorrect because numbness typically indicates neurological rather than vascular perfusion problems requiring different interventions and assessments.
Option d is incorrect because numbness represents sensory loss, not pain syndrome development requiring pain management interventions or treatments.

Correct Answer: Back massage for relaxation

Back massage promotes relaxation through therapeutic touch, reducing anxiety and encouraging natural sleep without pharmaceutical side effects.
Option a is incorrect because television stimulation, even quiet, further disrupts sleep patterns rather than promoting restful natural sleep.
Option c is incorrect because caffeine is a stimulant that worsens insomnia, directly contradicting sleep promotion goals and interventions.
Option d is incorrect because bright lights suppress melatonin production, making sleep more difficult rather than promoting natural rest.

Correct Answer: Two healthcare witnesses needed

Advance directives require two healthcare witnesses not involved in direct patient care, without requiring attorney involvement or notarization.
Option a is incorrect because attorneys aren't legally required for advance directives though patients may choose legal consultation if desired.
Option c is incorrect because notarization isn't required for advance directives to be legally valid with appropriate witness signatures present.
Option d is incorrect because family approval isn't needed; competent adults make independent advance directive decisions about their care.

Correct Answer: Auscultate bilateral lung sounds

Lung auscultation identifies pulmonary edema and crackles indicating fluid in lungs requiring immediate intervention to prevent respiratory failure.
Option a is incorrect because peripheral edema assessment is less urgent than identifying pulmonary fluid threatening respiratory function immediately.
Option c is incorrect because abdominal measurements don't address the immediate respiratory threat from pulmonary fluid accumulation requiring intervention.
Option d is incorrect because weighing delays critical respiratory assessment when pulmonary edema may require emergent treatment for breathing.

Correct Answer: Weight bearing through palms

Palm weight bearing prevents axillary nerve compression that causes permanent damage when armpits bear body weight improperly.
Option a is incorrect because armpit weight bearing compresses nerves and vessels causing numbness, weakness, and potential permanent damage.
Option c is incorrect because leaning heavily increases pressure on axillary nerves regardless of fatigue, risking permanent neurological damage.
Option d is incorrect because dragging feet indicates improper crutch technique and doesn't relate to preventing nerve damage specifically.

Correct Answer: Flush with thirty milliliters

Thirty milliliter flushes before and after medications prevent tube occlusion while ensuring complete medication delivery into stomach.
Option a is incorrect because x-ray confirmation isn't required for each medication administration after initial placement verification is completed.
Option c is incorrect because aspirating all contents before medications could remove previously administered medications or feeding unnecessarily.
Option d is incorrect because clamping prevents normal gastric emptying and doesn't improve medication absorption, potentially causing reflux.

Correct Answer: Maintain cool dark room

Cool, dark environments promote melatonin production and prevent sleep disruption from light or temperature discomfort affecting rest.
Option a is incorrect because television light and sound, even quiet, stimulate the brain preventing deep restorative sleep cycles.
Option c is incorrect because bright lights suppress melatonin and disrupt circadian rhythms necessary for quality sleep patterns nightly.
Option d is incorrect because continuous music may prevent deep sleep stages even if initially relaxing for falling asleep.

Correct Answer: Stop the feeding infusion

Immediately stopping feeding prevents additional formula entering potentially compromised airways while allowing assessment and intervention for safety.
Option a is incorrect because checking placement delays stopping the source of potential aspiration requiring immediate cessation for safety.
Option c is incorrect because elevation without first stopping feeding allows continued formula delivery into potentially compromised airways dangerously.
Option d is incorrect because suctioning before stopping feeding source allows continued aspiration while attempting to clear airways ineffectively.

Correct Answer: Reposition every two hours

Regular repositioning every two hours redistributes pressure, preventing ischemia and tissue damage that causes pressure ulcer formation.
Option a is incorrect because massaging reddened areas can damage fragile tissues and worsen developing pressure injuries rather than preventing them.
Option c is incorrect because heat application increases metabolic demands on already compromised tissue, accelerating breakdown rather than prevention.
Option d is incorrect because excessively dry skin cracks and breaks down; balanced moisture maintains skin integrity better overall.

Correct Answer: Your identity and unit

SBAR situation component begins with nurse identification and unit location, establishing context before presenting clinical information to physicians.
Option a is incorrect because vital signs belong in assessment section after situation and background information has been provided first.
Option c is incorrect because recommendations come last in SBAR format after situation, background, and assessment are communicated clearly.
Option d is incorrect because admission diagnosis is background information provided after initial situation identification and context are established.

Correct Answer: Edges are well approximated

Well-approximated edges indicate proper surgical alignment enabling primary intention healing without gaps or tissue formation visible externally.
Option a is incorrect because granulation tissue indicates secondary intention healing, not the expected primary intention from surgical closure.
Option c is incorrect because continuous moderate drainage suggests possible infection or healing complications rather than normal primary healing.
Option d is incorrect because gaping indicates dehiscence or poor closure preventing primary intention healing from occurring properly postoperatively.