D439 Foundations of Nursing - Set 2 - Part 2

Correct Answer: Encouraging nutritional supplement intake

Pushing supplements violates patient autonomy and comfort care principles when terminal patients choose to refuse nutritional intake.
Option a is incorrect because ice chips provide oral moisture comfort without forcing unwanted fluid intake against patient wishes.
Option b is incorrect because lip moisturizer prevents painful cracking and provides comfort without violating refusal of intake.
Option d is incorrect because moisture sprays comfort dry mucous membranes respecting the patient's choice to refuse oral intake.

Correct Answer: One inch field border

The one-inch perimeter border of sterile fields is considered non-sterile, providing a safety margin for handling without contamination.
Option a is incorrect because the field center is the most sterile area where sterile items should be placed during procedures.
Option c is incorrect because while items below waist are non-sterile, this describes positioning rather than field borders specifically.
Option d is incorrect because sterile glove outer surfaces remain sterile when properly donned and are used for handling sterile items.

Correct Answer: Ask about existing directives

The Patient Self-Determination Act legally requires healthcare facilities to ask patients about existing advance directives upon admission.
Option a is incorrect because attorney referral isn't required by law; patients can complete advance directives without legal representation needed.
Option c is incorrect because family meetings aren't legally required; competent patients make independent advance directive decisions themselves.
Option d is incorrect because physician approval isn't needed for patients to create advance directives expressing their healthcare wishes.

Correct Answer: Pull earlobe down back

Children's shorter, straighter ear canals require pulling the earlobe down and back for proper medication flow, unlike adults.
Option a is incorrect because cold medications cause discomfort and vertigo; room temperature is appropriate for all ages receiving drops.
Option c is incorrect because deeper insertion risks injury and isn't necessary; drops flow naturally when canal is properly positioned.
Option d is incorrect because tragus massage technique doesn't differ between children and adults after proper medication instillation is completed.

Correct Answer: Only abnormal findings discovered

Charting by exception documents only abnormal findings, with normal assessments assumed unless specifically noted as abnormal or absent.
Option a is incorrect because documenting all normal findings defeats the purpose of exception-based charting's efficiency for documentation.
Option c is incorrect because time alone doesn't indicate what was assessed or whether findings were normal or abnormal.
Option d is incorrect because some documentation is required to show assessments were performed, even if findings were all normal.

Correct Answer: Thirty milliliters of water

Thirty milliliters provides adequate volume to clear the tube before and after feedings without causing excessive fluid administration.
Option a is incorrect because fifteen milliliters insufficiently clears longer tubes of formula residue that could cause clogging over time.
Option c is incorrect because sixty milliliters exceeds necessary volume for routine flushing, potentially causing fluid overload with frequent administration.
Option d is incorrect because one hundred milliliters is excessive for routine flushes and may cause gastric distention or discomfort.

Correct Answer: Only medications no compressions

Chemical codes involve medication administration only without chest compressions, defibrillation, or other physical resuscitation measures during cardiac arrest.
Option a is incorrect because chemical codes still involve medication interventions, not complete withholding of all treatment measures entirely.
Option c is incorrect because full codes include all interventions while chemical codes specifically exclude physical resuscitation measures like compressions.
Option d is incorrect because allowing natural death means no interventions while chemical codes still include medication administration attempts.

Correct Answer: Excessive sweating is present

Diaphoresis specifically describes excessive sweating that may indicate fever, pain, anxiety, or other physiological stress responses occurring.
Option a is incorrect because diaphoresis represents abnormal excessive sweating beyond normal temperature regulation mechanisms in the body.
Option c is incorrect because while sweating causes fluid loss, diaphoresis describes the sweating itself, not resulting dehydration status.
Option d is incorrect because hypothermia causes shivering and vasoconstriction to preserve heat, not the sweating of diaphoresis.

Correct Answer: Outside the room completely

Masks for droplet precautions must remain on until completely outside the patient room to prevent respiratory droplet transmission.
Option a is incorrect because one foot is well within droplet transmission range, requiring continued mask use for protection.
Option b is incorrect because three feet is the minimum distance droplets travel, but masks stay on until leaving the room.
Option c is incorrect because six feet may exceed typical droplet range but protocol requires keeping masks on until outside rooms.

Correct Answer: Initial admission assessment performing

Initial assessments require nursing judgment and cannot be delegated to UAPs who lack assessment training and scope of practice.
Option a is incorrect because bathing stable patients is an appropriate UAP task within their training and scope of practice.
Option c is incorrect because feeding cooperative patients who don't have swallowing difficulties is an appropriate UAP delegation task.
Option d is incorrect because assisting with ambulation for stable patients is within UAP scope when parameters are clearly defined.

Correct Answer: Forty-five degrees left side

Positioning the wheelchair at forty-five degrees on the patient's stronger left side facilitates safer transfer using functional strength.
Option a is incorrect because perpendicular positioning doesn't optimize use of the patient's stronger side for safe transfer mechanics.
Option b is incorrect because parallel positioning makes transfer difficult requiring unnecessary reaching and twisting during movement activities.
Option d is incorrect because positioning on the weak right side compromises safety by requiring use of impaired strength for transfer.

Correct Answer: Decreased skin turgor present

Poor skin turgor suggests dehydration requiring specific gravity testing to confirm concentrated urine from fluid volume deficit.
Option a is incorrect because clear yellow urine indicates normal hydration not requiring specific gravity testing for evaluation purposes.
Option c is incorrect because nocturia has many causes beyond fluid status, making specific gravity less diagnostically useful initially.
Option d is incorrect because burning suggests infection requiring urinalysis and culture rather than specific gravity for fluid status.

Correct Answer: Taking naps after lunch

Afternoon naps disrupt nighttime sleep patterns and should be avoided or limited to twenty minutes twice daily maximum.
Option a is incorrect because light afternoon exercise actually promotes better nighttime sleep when done several hours before bedtime.
Option b is incorrect because bright light exposure during daytime hours helps maintain circadian rhythms for better nighttime sleep.
Option d is incorrect because afternoon hydration is important though fluids should be limited closer to bedtime to prevent nocturia.

Correct Answer: Discussing patient in elevator

Elevator discussions violate HIPAA as unauthorized individuals may overhear protected health information in these public spaces inadvertently.
Option b is incorrect because secure screen viewing protects patient information from unauthorized visual access, following HIPAA requirements properly.
Option c is incorrect because shredding patient information represents proper disposal of protected health information per HIPAA regulations correctly.
Option d is incorrect because logging off when leaving computers prevents unauthorized access, demonstrating appropriate HIPAA compliance for security.

Correct Answer: Flexion and extension movements

Hinge joints like elbows and knees move in one plane through flexion and extension movements only, not rotation.
Option a is incorrect because circular rotation occurs in ball-and-socket joints, not the single-plane movement of hinge joints mechanically.
Option c is incorrect because abduction and adduction occur at joints allowing side-to-side movement, not hinge joint mechanics.
Option d is incorrect because circumduction combines multiple movements impossible in hinge joints limited to flexion and extension only.

Correct Answer: Feeding bag and tubing

Feeding bags and tubing require daily changes to prevent bacterial growth in formula residue that could cause infection.
Option a is incorrect because pumps and poles are cleaned but not changed daily, as they don't contact formula directly.
Option b is incorrect because nasogastric tubes remain in place for weeks with proper care, not requiring daily replacement.
Option d is incorrect because pulse oximetry probes aren't related to enteral feeding and don't require routine scheduled changes.

Correct Answer: Cyanosis of lips appearing

Cyanosis indicates dangerous hypoxia requiring immediate suctioning cessation and oxygen administration to prevent cardiac complications or arrest.
Option a is incorrect because increased secretions are expected during suctioning and don't indicate hypoxia development requiring intervention immediately.
Option b is incorrect because coughing is a normal response to suctioning stimulation not necessarily indicating hypoxia requiring cessation.
Option d is incorrect because discomfort is expected with suctioning while cyanosis represents life-threatening hypoxia requiring immediate action.

Correct Answer: Prevent aspiration pneumonia risk

Thirty-degree elevation uses gravity to prevent reflux and aspiration of feeding into lungs, reducing pneumonia risk significantly.
Option a is incorrect because while elevation may aid digestion slightly, the primary purpose is preventing aspiration, not improving absorption.
Option c is incorrect because elevation doesn't significantly reduce residual volumes; it prevents their reflux into the airway primarily.
Option d is incorrect because comfort is secondary to the critical safety goal of preventing potentially fatal aspiration pneumonia development.

Correct Answer: I'll tighten thigh hold ten

Isometric quadriceps exercises involve tightening thigh muscles and holding without joint movement, safe for healing fractures with hardware.
Option a is incorrect because knee bending involves joint movement inappropriate for isometric exercises during fracture healing with hardware present.
Option c is incorrect because leg lifting requires hip and knee movement, not the stationary muscle contraction of isometric exercises.
Option d is incorrect because hip rotation involves joint movement that could compromise fracture healing and hardware positioning stability.

Correct Answer: Decreasing white blood cells

Decreasing white blood cell counts indicate the infection is resolving with effective antibiotic therapy reducing inflammatory response appropriately.
Option a is incorrect because rising white cells suggest worsening infection or antibiotic resistance requiring therapy modification immediately for effectiveness.
Option c is incorrect because hemoglobin levels don't directly reflect infection status or antibiotic effectiveness against MRSA infections specifically.
Option d is incorrect because platelet counts may rise with inflammation but don't specifically indicate antibiotic effectiveness against infection.