D439 Foundations of Nursing - Set 4 - Part 1

Correct Answer: Tighten thigh muscle hold

Isometric exercises involve muscle contraction without joint movement, perfect for maintaining strength while protecting healing fractures with hardware.
Option a is incorrect because knee bending requires joint movement that could compromise fracture healing and hardware stability during recovery.
Option b is incorrect because leg lifting involves hip and knee movement inappropriate for isometric exercises with healing fractures present.
Option d is incorrect because ankle rotation involves joint movement rather than the static muscle contraction of isometric exercises required.

Correct Answer: Don surgical mask entering

Surgical masks protect against large respiratory droplets that transmit bacterial meningitis within three feet of infected patients effectively.
Option a is incorrect because N95 respirators are for airborne precautions, not the larger droplets that transmit bacterial meningitis typically.
Option c is incorrect because negative pressure rooms are for airborne precautions, not droplet transmission which meningitis typically uses.
Option d is incorrect because droplets typically travel three feet, making ten feet unnecessarily restrictive for care delivery requirements.

Correct Answer: Debridement of necrotic tissue

Eschar removal through debridement allows visualization of wound depth and tissue involvement necessary for accurate staging determination clinically.
Option a is incorrect because antibiotics treat infection but don't remove eschar preventing wound visualization for staging assessment needed.
Option c is incorrect because while nutrition supports healing, it doesn't remove the eschar obscuring wound depth for staging.
Option d is incorrect because circulation improvement doesn't remove necrotic tissue preventing accurate assessment of wound depth for staging.

Correct Answer: Patient autonomy takes precedence

Competent patients have the right to refuse treatment including nutrition, with autonomy overriding family wishes regarding feeding decisions.
Option a is incorrect because beneficence doesn't override patient autonomy when competent adults make informed decisions about their care.
Option c is incorrect because family cannot override competent patient decisions about their own medical care and treatment choices.
Option d is incorrect because non-maleficence involves not causing harm but doesn't override patient autonomy for self-determination rights.

Correct Answer: Respiratory distress is occurring

Accessory muscle use indicates increased work of breathing when diaphragmatic breathing alone cannot meet oxygen demands adequately.
Option a is incorrect because normal breathing relies primarily on diaphragm movement without recruiting additional neck and chest muscles.
Option c is incorrect because improved capacity would reduce breathing effort, not require additional muscle recruitment for adequate ventilation.
Option d is incorrect because decreased oxygen needs would reduce breathing effort rather than requiring accessory muscle use observed.

Correct Answer: Avoid afternoon naps completely

Eliminating afternoon naps preserves sleep drive for nighttime, improving ability to fall and stay asleep during normal hours.
Option a is incorrect because vigorous exercise before bed stimulates the body, making sleep more difficult rather than promoting rest.
Option c is incorrect because television's light and stimulation interfere with melatonin production and mental preparation for sleep naturally.
Option d is incorrect because while traditionally recommended, dairy products don't consistently improve sleep and may cause digestive discomfort.

Correct Answer: Use back forth motions

Back and forth cleansing motions effectively remove contaminants without recontaminating cleaned areas, maintaining asepsis during catheter care properly.
Option a is incorrect because leaving foreskin retracted causes paraphimosis, painful swelling requiring emergency intervention to prevent tissue damage.
Option b is incorrect because circular motions risk bringing contaminated solution back over cleaned areas, increasing infection risk significantly.
Option d is incorrect because routine antibiotic ointment isn't recommended and may promote resistant organism growth around catheter sites.

Correct Answer: Bananas for potassium replacement

Bananas provide potassium to replace losses from diuretic therapy, preventing dangerous hypokalemia that affects cardiac function adversely.
Option a is incorrect because canned soup's high sodium content worsens fluid retention, counteracting diuretic therapy for heart failure.
Option b is incorrect because white bread lacks significant fiber and doesn't address electrolyte replacement needs from diuretic therapy.
Option d is incorrect because coffee's caffeine has diuretic effects that worsen fluid and electrolyte losses rather than replacing them.

Correct Answer: Massage the purple area

Massaging deep tissue injury areas causes additional trauma to already damaged tissue, accelerating breakdown rather than promoting healing.
Option a is incorrect because repositioning redistributes pressure appropriately, preventing further tissue damage while promoting perfusion to injured areas.
Option c is incorrect because pressure redistribution surfaces appropriately reduce pressure on injured tissue, supporting healing rather than causing harm.
Option d is incorrect because adequate nutrition provides protein and nutrients essential for tissue repair and healing processes needed.

Correct Answer: Probe placement and signal

Verifying proper probe placement eliminates false low readings from poor positioning before assuming actual hypoxemia requiring intervention urgently.
Option a is incorrect because flow meter checks follow probe verification since false readings mislead about actual oxygenation status present.
Option c is incorrect because hemoglobin testing delays immediate assessment when probe malposition may explain abnormal readings observed initially.
Option d is incorrect because lung assessment follows confirmation that low readings are accurate rather than equipment-related false readings.

Correct Answer: Assigns decision-making to another

Durable power of attorney designates someone to make medical decisions when patients cannot communicate their wishes themselves effectively.
Option a is incorrect because power of attorney and living wills serve different purposes and work together for comprehensive advance planning.
Option c is incorrect because attorneys aren't required for durable power of attorney completion though legal consultation remains available optionally.
Option d is incorrect because durable power of attorney activates when patients cannot make decisions, not after death when it terminates.

Correct Answer: Check feeding formula temperature

Cold formula commonly causes diarrhea in enteral feeding; warming to room temperature often resolves this problem without stopping nutrition.
Option a is incorrect because permanently stopping feeding eliminates nutrition when simple adjustments like temperature modification may resolve diarrhea.
Option b is incorrect because increasing rate worsens diarrhea by overwhelming digestive capacity rather than addressing the underlying cause present.
Option d is incorrect because parenteral nutrition has greater risks and shouldn't replace enteral feeding for manageable complications like diarrhea.

Correct Answer: Inhales slowly and deeply

Slow, deep inhalation maximizes lung expansion preventing atelectasis and pneumonia after surgery when respiratory effort is compromised.
Option a is incorrect because incentive spirometry requires inhalation not exhalation to expand lungs and prevent postoperative pulmonary complications.
Option c is incorrect because rapid breathing causes hyperventilation without achieving the sustained lung expansion needed for prevention.
Option d is incorrect because holding breath before use doesn't prepare lungs; the slow deep inspiration provides therapeutic benefit.

Correct Answer: Excessive sweating is occurring

Diaphoresis specifically means profuse sweating that may indicate fever, pain, anxiety, or other physiological stress responses present.
Option a is incorrect because diaphoresis describes sweating itself, not temperature elevation though fever often causes diaphoretic episodes clinically.
Option c is incorrect because shivering and chills are different responses to temperature changes, not the sweating of diaphoresis.
Option d is incorrect because while sweating causes fluid loss, diaphoresis describes the sweating process, not resulting dehydration status.

Correct Answer: Obtain order within hour

Emergency restraint application requires physician order within one hour to meet regulatory requirements while maintaining patient safety appropriately.
Option a is incorrect because immediate removal without assessment may endanger patient or others if restraints were applied for safety.
Option c is incorrect because while documentation is important, obtaining required orders takes priority for legal compliance and safety.
Option d is incorrect because family notification follows obtaining proper orders and ensuring regulatory compliance for restraint use legally.

Correct Answer: Keep thumb over label

Protecting labels with thumb prevents solution from obscuring medication identification while maintaining sterile technique during pouring procedures.
Option a is incorrect because pouring across fields risks contamination from drips or spills onto sterile areas during solution transfer.
Option c is incorrect because bottle contact with sterile containers contaminates both the container and potentially the solution being poured.
Option d is incorrect because excessive height causes splashing that contaminates sterile fields through moisture spread and droplet formation.

Correct Answer: Glucose pulls water out

High blood glucose creates osmotic diuresis as excess glucose in urine pulls water along, increasing urination volume and frequency.
Option a is incorrect because while infections cause frequency, diabetic nocturia specifically results from hyperglycemia's osmotic effects, not infection necessarily.
Option c is incorrect because nocturia from hyperglycemia doesn't indicate kidney damage but rather the kidneys' attempt to excrete excess glucose.
Option d is incorrect because prostate issues affect only males while diabetic nocturia affects all patients through metabolic mechanisms universally.

Correct Answer: Eight twelve four eight

Vital signs begin at admission time then continue every four hours from that baseline for consistent monitoring intervals maintained.
Option a is incorrect because midnight start doesn't reflect actual admission time and delays initial assessment unnecessarily for hours.
Option c is incorrect because starting at nine delays initial assessment when patient arrived at eight requiring immediate baseline vitals.
Option d is incorrect because ten o'clock start inappropriately delays initial vital signs two hours after patient admission occurred.

Correct Answer: Perform frequent hand hygiene

Hand hygiene is the single most effective measure preventing MRSA transmission through contact with contaminated hands or surfaces.
Option a is incorrect because masks aren't necessary for MRSA prevention at home since it spreads through contact, not airborne transmission.
Option b is incorrect because room isolation isn't required at home when proper hygiene and wound covering prevent transmission effectively.
Option d is incorrect because prophylactic antibiotics aren't recommended and may promote further resistance development rather than preventing transmission.

Correct Answer: Medications only no compressions

Chemical codes involve medication administration during cardiac arrest without physical interventions like compressions or electrical therapy attempted.
Option a is incorrect because full codes include all interventions while chemical codes specifically exclude physical resuscitation measures during arrest.
Option c is incorrect because chemical codes still involve medication interventions rather than complete withholding of all resuscitation attempts.
Option d is incorrect because allowing natural death means no interventions while chemical codes include pharmacological intervention attempts during arrest.