D439 Foundations of Nursing - Set 3 - Part 2

Correct Answer: Legs crossed during measurement

Crossed legs increase peripheral resistance and venous return, artificially elevating blood pressure readings by ten to fifteen points.
Option a is incorrect because arm positioning at heart level ensures accurate readings without hydrostatic pressure effects on measurements.
Option c is incorrect because proper cuff size prevents false readings from inappropriate bladder size relative to arm circumference.
Option d is incorrect because quiet rest before measurement allows cardiovascular stabilization for accurate baseline blood pressure readings.

Correct Answer: Replace the entire field

Moisture anywhere on sterile fields allows bacterial transmission through wicking, contaminating the field and requiring complete replacement immediately.
Option a is incorrect because continuing with contaminated field risks surgical site infection regardless of caution level exercised during procedure.
Option b is incorrect because drying doesn't eliminate contamination already present from moisture breaching the sterile barrier completely throughout.
Option d is incorrect because covering contamination doesn't restore sterility; the field is compromised requiring complete replacement for safety.

Correct Answer: With the next voiding

Collection begins with next void after discarding current urine, establishing empty bladder baseline for accurate twenty-four hour collection.
Option a is incorrect because immediate collection after voiding would miss establishing the empty bladder baseline needed for accuracy.
Option c is incorrect because arbitrary morning timing doesn't ensure proper baseline establishment from known empty bladder state initially.
Option d is incorrect because forcing fluids before starting affects natural voiding patterns and concentration during collection period unnecessarily.

Correct Answer: Avoid aspiration before injection

Avoiding aspiration prevents tissue trauma and hematoma formation when administering anticoagulants into subcutaneous tissue with fragile capillaries.
Option a is incorrect because massaging anticoagulant injection sites increases bruising by spreading medication and causing tissue trauma unnecessarily.
Option c is incorrect because pressure after heparin injection causes hematoma formation by forcing blood from damaged capillaries into tissues.
Option b is incorrect because aspiration with anticoagulants causes unnecessary tissue trauma increasing bleeding and bruising at injection sites.

Correct Answer: Gown and gloves only

MRSA contact precautions require gown and gloves to prevent transmission through direct contact with contaminated surfaces or patient.
Option a is incorrect because N95 respirators are for airborne precautions; MRSA spreads through contact, not airborne transmission routes.
Option c is incorrect because masks aren't required for contact precautions unless splashing is anticipated during specific procedures performed.
Option d is incorrect because full protective suits exceed requirements for contact precautions and are reserved for special circumstances only.

Correct Answer: Kidney failure developing progressively

Very low specific gravity indicates kidneys cannot concentrate urine properly, suggesting renal failure or significant kidney dysfunction present.
Option a is incorrect because normal specific gravity ranges from one point zero zero five to one point zero three zero typically.
Option b is incorrect because dehydration causes high specific gravity from concentrated urine, not the dilute urine indicated here.
Option d is incorrect because urinary infections don't specifically affect specific gravity unless kidney function is compromised significantly as well.

Correct Answer: Only abnormal findings noted

Charting by exception documents only deviations from normal, assuming normal findings unless specifically documented as abnormal or concerning.
Option a is incorrect because documenting all normal findings defeats the efficiency purpose of exception-based charting systems used clinically.
Option c is incorrect because time alone doesn't indicate what assessments were performed or whether findings were normal or abnormal.
Option d is incorrect because some documentation is required showing assessments were completed even when all findings are normal.

Correct Answer: Prevent medication from draining

Punctal occlusion blocks tear ducts preventing medication drainage through nasolacrimal system, maximizing ocular contact time for therapeutic effect.
Option b is incorrect because punctal occlusion actually decreases systemic absorption by preventing drainage into nasal passages and systemic circulation.
Option c is incorrect because the technique primarily improves efficacy rather than reducing local effects, though systemic effects decrease beneficially.
Option d is incorrect because comfort isn't the primary goal; maximizing therapeutic effect through prolonged eye contact is the purpose.

Correct Answer: Stop taking insulin doses

Stopping insulin worsens hyperglycemia causing increased nocturia through osmotic diuresis, requiring immediate re-education about diabetes management principles.
Option a is incorrect because glucose control reduces nocturia by preventing osmotic diuresis, showing good understanding of symptom management strategies.
Option b is incorrect because limiting evening fluids appropriately reduces nighttime urination while maintaining adequate daily hydration for health.
Option d is incorrect because avoiding caffeine's diuretic effect represents appropriate understanding of factors that worsen nocturia symptoms nightly.

Correct Answer: Ask about the grimacing

Exploring grimacing reasons helps identify whether pain exists despite denial or other factors explain the nonverbal expression observed.
Option a is incorrect because accepting denial without investigating contradictory nonverbal cues may miss treatable pain or other problems.
Option c is incorrect because documenting without exploring the discrepancy between verbal and nonverbal communication provides incomplete assessment data.
Option d is incorrect because administering medications without confirmed need violates informed consent and safe medication administration principles fundamentally.

Correct Answer: Predictable bowel movements daily

Predictable daily bowel movements indicate successful training establishing regular patterns that prevent incontinence episodes and improve quality of life.
Option a is incorrect because decreased frequency may indicate constipation rather than successful bowel training for continence management effectively achieved.
Option c is incorrect because laxative dependence indicates program failure as training should establish natural bowel patterns without medications.
Option d is incorrect because suppository dependence shows inability to achieve natural bowel function, not successful training program implementation results.

Correct Answer: Admission diagnosis and history

Background section includes admission diagnosis, relevant history, and pertinent test results providing context for current situation being reported.
Option a is incorrect because current symptoms belong in assessment section where present status and concerns are communicated to providers.
Option c is incorrect because recommendations comprise the final SBAR component after situation, background, and assessment are presented completely.
Option d is incorrect because patient identification belongs in situation section at the beginning of SBAR communication, not background information.

Correct Answer: Inspect feet daily thoroughly

Daily inspection identifies injuries or problems that neuropathy prevents patients from feeling, enabling early intervention preventing serious complications.
Option a is incorrect because hot water can burn insensitive feet and soaking macerates skin, increasing infection risk significantly for patients.
Option c is incorrect because very short nail trimming risks injury to surrounding tissue that neuropathy prevents patients from feeling immediately.
Option d is incorrect because barefoot walking risks undetected injuries from objects when protective sensation is absent from neuropathy damage.

Correct Answer: Keep tanks in cool area

Cool storage prevents dangerous pressure increases in compressed oxygen cylinders that could cause explosion or rapid gas release.
Option a is incorrect because bathroom humidity causes valve corrosion and moisture isn't appropriate for oxygen equipment storage safely.
Option c is incorrect because heat sources dangerously increase cylinder pressure risking explosion, requiring minimum eight-foot distance for safety.
Option d is incorrect because closed spaces without ventilation concentrate oxygen creating fire hazards if leaks develop in equipment.

Correct Answer: Side-lying position for drainage

Side-lying positioning allows gravity drainage of fluids away from airway, preventing aspiration during oral care procedures safely.
Option a is incorrect because supine positioning allows fluid accumulation in posterior pharynx significantly increasing aspiration risk during care.
Option c is incorrect because maintaining unconscious patients fully upright is difficult and unstable for providing thorough oral care.
Option d is incorrect because Trendelenburg position directs fluids toward lungs, dramatically increasing aspiration risk rather than preventing it.

Correct Answer: AND focuses on comfort

Allow Natural Death emphasizes comfort care and natural dying process while DNR specifically addresses resuscitation efforts during cardiac arrest.
Option a is incorrect because while similar, AND has more positive framing focusing on comfort rather than withholding specific interventions.
Option b is incorrect because DNR only addresses resuscitation during cardiac arrest, not all medical treatments or interventions generally.
Option d is incorrect because DNR specifically addresses resuscitation efforts while AND encompasses broader comfort-focused end-of-life care approaches.

Correct Answer: Prongs curve downward naturally

Downward curving prongs follow natural nasal anatomy for comfortable fit and optimal oxygen flow into nasal passages effectively.
Option a is incorrect because proper placement involves tubing over ears, not behind them, to maintain proper positioning during movement.
Option c is incorrect because tight placement over ears causes pressure injuries; tubing should rest comfortably without excessive pressure applied.
Option d is incorrect because upward-facing prongs direct oxygen away from nasal passages, reducing therapeutic effectiveness of oxygen delivery.

Correct Answer: One hundred twenty millimeters

Inflating thirty millimeters above pulse disappearance ensures accurate systolic capture without excessive pressure causing patient discomfort unnecessarily applied.
Option a is incorrect because only ten millimeters above may miss true systolic pressure if pulse disappearance was detected late.
Option b is incorrect because twenty millimeters may be insufficient margin for accurate systolic pressure determination in some patients clinically.
Option d is incorrect because sixty millimeters above causes unnecessary discomfort without improving measurement accuracy for blood pressure determination.

Correct Answer: Purulent drainage increasing daily

Increasing purulent drainage indicates bacterial infection requiring intervention with antibiotics and possible wound culture for treatment guidance.
Option a is incorrect because well-approximated edges indicate proper healing without separation or infection signs requiring intervention currently needed.
Option b is incorrect because minimal serous drainage is normal during initial healing and doesn't indicate infection requiring treatment.
Option d is incorrect because pink tissue indicates healthy granulation and healing rather than infection requiring medical intervention immediately.

Correct Answer: Secure to bed frame

Bed frame attachment ensures restraints remain properly positioned regardless of rail movement, preventing injury from sudden tightening or loosening.
Option a is incorrect because rail attachment causes dangerous restraint changes when rails are adjusted, risking patient injury significantly.
Option b is incorrect because circulation checks are required every fifteen minutes initially, not hourly, to prevent tissue damage.
Option c is incorrect because slip knots, not square knots, allow quick release in emergencies while maintaining secure restraint when needed.