D439 Foundations of Nursing - Set 5 - Part 1

Correct Answer: Collect stool sample proceed

Occult blood requires investigation through laboratory testing to identify bleeding sources while continuing routine care and monitoring appropriately.
Option a is incorrect because occult blood is never normal and requires investigation to determine the source of gastrointestinal bleeding present.
Option c is incorrect because laxatives may worsen bleeding and shouldn't be given without determining the cause of occult blood first.
Option d is incorrect because diabetic medications aren't related to occult blood and withholding them could cause dangerous hyperglycemia unnecessarily.

Correct Answer: Lung sounds auscultation bilaterally

Lung assessment identifies pulmonary edema requiring immediate intervention to prevent respiratory failure from fluid accumulation in lungs.
Option a is incorrect because while weight tracks fluid changes, pulmonary assessment takes priority for identifying life-threatening pulmonary edema immediately.
Option c is incorrect because peripheral edema is less urgent than pulmonary fluid that directly threatens respiratory function and oxygenation.
Option d is incorrect because monitoring is important but assessing for pulmonary complications takes priority over tracking fluid balance numbers.

Correct Answer: Nurse name and unit

Situation begins with nurse identification, unit location, and patient identification establishing context before presenting clinical information to physicians.
Option a is incorrect because vital signs and laboratory values belong in the assessment section after situation and background are provided.
Option c is incorrect because treatment recommendations are the final SBAR component after all clinical information has been communicated clearly.
Option d is incorrect because medical history and medications are background information provided after initial situation identification is established first.

Correct Answer: Pull earlobe down back

Children's shorter, straighter ear canals require pulling down and back unlike adults who need up and back positioning.
Option a is incorrect because room temperature medication is appropriate for all ages to prevent vertigo from temperature extremes during administration.
Option c is incorrect because all patients should lie still during administration regardless of age for proper medication delivery achieved.
Option d is incorrect because dropper depth doesn't vary by age; it shouldn't enter the canal deeply for any patient.

Correct Answer: Ask why they're grimacing

Exploring the grimacing helps identify whether pain exists despite denial or if other factors explain the facial expression.
Option a is incorrect because documenting without investigating the contradiction between verbal and nonverbal cues provides incomplete assessment information needed.
Option b is incorrect because administering medication without confirmed pain violates informed consent and safe medication administration principles fundamentally required.
Option d is incorrect because ignoring nonverbal indicators may miss significant pain or other problems requiring nursing intervention promptly addressed.

Correct Answer: Predictable elimination pattern established

Establishing predictable bowel patterns without medication dependence indicates successful training program implementation improving continence and independence for patients.
Option a is incorrect because daily laxative use indicates program failure as training should establish natural patterns without medication dependence developing.
Option c is incorrect because continuous suppository need shows inability to achieve independent bowel function through training program efforts alone.
Option d is incorrect because decreased frequency may indicate constipation rather than successful bowel training achieving regular elimination patterns desired.

Correct Answer: Ten percent dextrose water

Dextrose solution prevents dangerous hypoglycemia when high-glucose parenteral nutrition is interrupted, maintaining blood sugar until replacement arrives safely.
Option a is incorrect because saline lacks glucose, risking severe hypoglycemia when transitioning from high-glucose parenteral nutrition suddenly without warning.
Option b is incorrect because lactated ringers doesn't provide adequate glucose to prevent hypoglycemia during parenteral nutrition interruption occurring unexpectedly.
Option d is incorrect because stopping completely causes dangerous hypoglycemia from sudden cessation of concentrated glucose delivery patients depend upon.

Correct Answer: Elevate head thirty degrees

Thirty-degree elevation helps maintain airway patency by preventing tongue and soft tissue from obstructing breathing during sleep periods.
Option a is incorrect because flat positioning worsens airway obstruction in sleep apnea by allowing tissues to collapse backward completely.
Option c is incorrect because stomach sleeping is uncomfortable with CPAP equipment and doesn't address upper airway obstruction effectively enough.
Option d is incorrect because multiple pillows may hyperextend the neck, potentially worsening airway obstruction rather than improving breathing patterns.

Correct Answer: Enter late entry correction

Late entry in correct chart with notation about error maintains legal documentation integrity while correcting the mistake appropriately made.
Option a is incorrect because deleting entries violates documentation standards and may appear as concealing errors rather than correcting them properly.
Option b is incorrect because risk management involvement isn't needed for documentation errors that can be corrected through proper procedures immediately.
Option d is incorrect because supervisor notification may follow but immediate correction through late entry takes priority for accuracy maintenance.

Correct Answer: Bone visible in wound

Stage four ulcers extend through all tissue layers exposing bone or muscle, requiring aggressive treatment preventing osteomyelitis and sepsis.
Option a is incorrect because intact reddened skin indicates stage one pressure injury without the extensive damage of stage four ulcers.
Option b is incorrect because blisters characterize stage two ulcers affecting only epidermis and dermis, not deeper stage four involvement.
Option c is incorrect because subcutaneous tissue exposure indicates stage three ulcers, not the bone involvement defining stage four wounds.

Correct Answer: Covers emergency aid given

Good Samaritan Laws protect individuals providing emergency assistance in good faith from legal liability for reasonable actions taken.
Option a is incorrect because Good Samaritan protection applies to anyone rendering aid, not just licensed medical professionals helping victims.
Option c is incorrect because protection specifically covers aid given outside healthcare facilities during emergencies, not hospital-based care provided.
Option d is incorrect because documentation isn't required for Good Samaritan protection which covers spontaneous emergency assistance rendered immediately necessary.

Correct Answer: Arm below heart level

Arms positioned below heart level cause falsely low readings due to hydrostatic pressure effects requiring proper positioning correction immediately.
Option a is incorrect because small cuffs cause falsely high readings as more pressure is needed to compress the artery adequately.
Option c is incorrect because uncrossed relaxed legs represent proper positioning that promotes accurate blood pressure measurement without interference occurring.
Option d is incorrect because talking typically raises blood pressure rather than causing the falsely low readings described in question.

Correct Answer: Provide back rub massage

Back massage promotes relaxation through therapeutic touch, encouraging natural sleep without medication side effects or safety risks present.
Option a is incorrect because sedatives increase fall risk and confusion in elderly patients, with non-pharmacological interventions preferred initially tried first.
Option c is incorrect because restraints are never appropriate for wandering and would violate patient rights without medical justification present.
Option d is incorrect because increased daytime napping reduces nighttime sleep drive, worsening insomnia rather than improving sleep patterns naturally.

Correct Answer: Daily foot inspection performed

Daily inspection identifies injuries that neuropathy prevents patients from feeling, enabling early treatment preventing serious complications like infections.
Option a is incorrect because hot water can burn insensitive feet and prolonged soaking macerates skin increasing infection risk significantly present.
Option b is incorrect because barefoot walking risks undetected injuries from objects when protective sensation is absent from nerve damage.
Option d is incorrect because cutting nails too short risks injury to surrounding tissue that patients cannot feel due to neuropathy.

Correct Answer: Feeding bag and tubing

Daily bag and tubing changes prevent bacterial growth in formula residue that could cause infection if contaminated equipment continues.
Option a is incorrect because nasogastric tubes remain in place for weeks with proper care, not requiring daily replacement changes unnecessarily.
Option c is incorrect because pumps and poles are cleaned but not changed daily since they don't contact formula directly requiring replacement.
Option d is incorrect because abdominal binders aren't related to enteral feeding equipment and don't require scheduled daily changes routinely performed.

Correct Answer: Edges well approximated together

Well-approximated edges indicate proper surgical closure alignment allowing primary intention healing without gaps or tissue formation visible between.
Option a is incorrect because separated edges indicate dehiscence preventing primary intention healing and requiring intervention to prevent complications developing further.
Option b is incorrect because abundant granulation tissue indicates secondary intention healing, not the expected primary intention from surgical closure.
Option d is incorrect because purulent drainage indicates infection rather than normal healing, requiring antibiotic therapy and wound culture immediately.

Correct Answer: Abdomen two inches from umbilicus

Abdominal subcutaneous tissue two inches from umbilicus provides consistent absorption while avoiding vascular areas that increase bleeding risk present.
Option a is incorrect because deltoid muscle is for intramuscular injections, not the subcutaneous route required for heparin administration properly given.
Option c is incorrect because anterior thigh muscle indicates intramuscular rather than subcutaneous injection site selection for heparin administration needed appropriately.
Option d is incorrect because ventrogluteal sites are for intramuscular injections while heparin requires subcutaneous administration for proper anticoagulation achieved safely.

Correct Answer: Record only abnormal findings

Exception charting documents only deviations from established norms, increasing efficiency while maintaining legal documentation requirements for patient care.
Option a is incorrect because documenting normal findings defeats the efficiency purpose of exception-based charting systems used for documentation streamlining.
Option c is incorrect because detailed narratives aren't required when findings are normal in exception-based documentation systems properly utilized effectively overall.
Option d is incorrect because charting everything contradicts exception-based principles designed to reduce documentation burden while maintaining safety standards required.

Correct Answer: Names my decision maker

Living wills express treatment preferences but don't name decision makers; that's the purpose of durable power of attorney documents.
Option a is incorrect because stating medical wishes is exactly what living wills do, indicating correct understanding of their purpose fundamentally.
Option c is incorrect because living wills do become effective when patients cannot communicate, showing accurate understanding of activation timing appropriately.
Option d is incorrect because while not entirely accurate about requirements, this shows basic understanding that witnessing is involved in completion.

Correct Answer: Apply protective padding strategically

Padding at pressure points prevents further skin breakdown while maintaining necessary oxygen therapy without interruption for respiratory needs met.
Option a is incorrect because discontinuing oxygen compromises respiratory status when simple padding could prevent damage while continuing therapy safely administered.
Option b is incorrect because changing delivery methods may not be appropriate for patient's needs when padding solves the problem identified effectively.
Option d is incorrect because flow rate changes don't address mechanical pressure causing skin breakdown from tubing contact with skin surfaces.