D439 Foundations of Nursing - Set 4 - Part 2

Correct Answer: Thirty milliliters of water

Thirty milliliters adequately clears tubes of formula residue preventing clogging without causing excessive fluid administration to patients.
Option a is incorrect because ten milliliters insufficiently clears longer feeding tubes of thick formula that accumulates causing occlusion.
Option c is incorrect because sixty milliliters exceeds necessary volume for routine maintenance, potentially causing fluid overload with frequency.
Option d is incorrect because ninety milliliters is excessive for routine flushes and may cause gastric distention or patient discomfort.

Correct Answer: Numbness in fingers developing

Finger numbness indicates brachial plexus compression from weight bearing through armpits rather than palms, risking permanent nerve damage.
Option a is incorrect because sore palms indicate proper weight bearing location though padding may improve comfort during crutch use.
Option c is incorrect because leg fatigue is expected with non-weight bearing ambulation and doesn't indicate nerve damage from crutches.
Option d is incorrect because shoulder stiffness may occur from new activity but doesn't specifically indicate nerve compression requiring intervention.

Correct Answer: Two healthcare workers witness

Hospital advance directives require two healthcare witnesses not involved in direct patient care, ensuring objectivity without requiring notarization.
Option a is incorrect because family members can be beneficiaries creating conflicts of interest; healthcare workers provide neutral witnessing appropriately.
Option c is incorrect because notarization isn't legally required for advance directives though some patients choose this additional verification optionally.
Option d is incorrect because physicians involved in care shouldn't witness advance directives due to potential conflicts of interest present.

Correct Answer: Apply heat and massage

Heat and massage promote circulation, reduce muscle tension, and provide sensory input that reduces pain perception naturally.
Option a is incorrect because appropriate activity maintains function and prevents deconditioning that worsens chronic pain over time progressively.
Option c is incorrect because bed rest causes muscle weakness and stiffness that exacerbate chronic pain rather than relieving it.
Option d is incorrect because discussing pain validates experiences and helps identify triggers and effective management strategies for relief.

Correct Answer: Change tubing immediately today

Enteral feeding tubing requires changing every twenty-four hours to prevent bacterial growth that could cause infection in patients.
Option a is incorrect because three-day-old tubing exceeds safe use duration, risking bacterial contamination and patient infection from overgrowth.
Option c is incorrect because flushing doesn't eliminate bacterial growth in tubing that's been used beyond recommended time limits.
Option d is incorrect because culturing delays necessary tubing change when time limits are already exceeded requiring immediate replacement instead.

Correct Answer: Irregular heart rhythm detected

Irregular cardiac rhythm from potassium imbalance can rapidly progress to lethal arrhythmias requiring immediate correction to prevent arrest.
Option a is incorrect because while muscle weakness occurs with potassium imbalance, it doesn't pose immediate life threat like cardiac effects.
Option c is incorrect because decreased bowel sounds indicate slowed motility but don't represent immediate danger requiring urgent intervention first.
Option d is incorrect because confusion is concerning but cardiac arrhythmias take priority as immediate life-threatening complications requiring intervention.

Correct Answer: Have patient demonstrate skills

Demonstration transcends language barriers by showing understanding through actions rather than relying on verbal communication for confirmation.
Option a is incorrect because patients may agree without understanding to be polite or avoid appearing confused about instructions given.
Option c is incorrect because written materials alone can't confirm understanding especially with potential literacy barriers beyond language differences.
Option d is incorrect because family interpretation may be inaccurate and doesn't confirm the patient's personal understanding of instructions provided.

Correct Answer: Wheelchair on left side

Positioning wheelchair on the stronger left side allows patients to use functional strength for safer, more controlled transfers independently.
Option a is incorrect because perpendicular positioning doesn't optimize use of the patient's stronger side for safe transfer mechanics needed.
Option b is incorrect because placing wheelchair on weak side compromises safety by requiring use of impaired strength for transfers.
Option d is incorrect because parallel positioning makes transfers difficult requiring awkward reaching and twisting movements during transfer activities.

Correct Answer: Store away from heat

Heat sources dangerously increase oxygen cylinder pressure risking explosion, requiring minimum eight-foot separation for safety at home.
Option a is incorrect because while equipment checks matter, improper storage near heat poses immediate explosion risk requiring priority emphasis.
Option c is incorrect because petroleum products should be completely avoided, not used sparingly, as they're flammable with oxygen present.
Option d is incorrect because smoking shouldn't occur anywhere near oxygen equipment, not just outside, due to fire risk present.

Correct Answer: Reposition every two hours

Regular repositioning redistributes pressure preventing tissue ischemia and cell death that causes pressure ulcer formation and progression inevitably.
Option a is incorrect because vigorous massage damages fragile tissues and capillaries, accelerating rather than preventing pressure ulcer development significantly.
Option b is incorrect because heat increases metabolic demands on already compromised tissue, potentially accelerating breakdown rather than prevention.
Option d is incorrect because excessively dry skin loses elasticity and cracks, while balanced moisture maintains healthy skin integrity better.

Correct Answer: AND sounds less harsh

Allow Natural Death provides gentler language focusing on comfort and natural process rather than withholding specific interventions like DNR.
Option a is incorrect because while similar in outcome, AND emphasizes comfort care philosophy rather than listing withheld interventions specifically.
Option c is incorrect because DNR only addresses resuscitation during arrest, not pain management which continues regardless of code status.
Option d is incorrect because AND doesn't stop all treatment but shifts focus to comfort while allowing natural dying process.

Correct Answer: Normal serous drainage expected

Clear serous drainage is normal during initial wound healing as plasma leaks from healing tissues without indicating complications present.
Option b is incorrect because infection produces purulent drainage with color and odor, not the clear serous drainage observed here.
Option c is incorrect because hemorrhage produces bloody drainage, not clear serous fluid from normal healing processes occurring postoperatively.
Option d is incorrect because dehiscence involves wound separation often with pink visceral tissue visible, not just clear drainage alone.

Correct Answer: Limit evening fluid intake

Limiting evening fluids reduces nocturia-related awakenings while maintaining adequate hydration during daytime hours for health needs met.
Option a is incorrect because afternoon naps reduce nighttime sleep drive, causing difficulty maintaining sleep through the night consistently.
Option b is incorrect because vigorous evening exercise stimulates the body, making sleep initiation and maintenance more difficult subsequently experienced.
Option d is incorrect because television's light and stimulation interfere with natural sleep preparation and melatonin production needed nightly.

Correct Answer: Over five hundred milliliters

Residuals exceeding five hundred milliliters indicate delayed gastric emptying requiring feeding cessation and physician notification for safety assessment.
Option a is incorrect because volumes under fifty milliliters indicate good gastric emptying allowing feeding continuation without concerns about aspiration.
Option b is incorrect because one hundred milliliters represents acceptable residual allowing continued feeding with ongoing monitoring for changes.
Option d is incorrect because two to three hundred milliliters, while elevated, typically allows continued feeding with increased monitoring frequency.

Correct Answer: Soap water hand washing

Soap and water physically removes C. difficile spores that alcohol-based sanitizers cannot kill, preventing transmission through hand contamination.
Option a is incorrect because C. difficile spreads through contact with spores, not airborne transmission requiring N95 respirator protection used.
Option b is incorrect because negative pressure rooms are for airborne precautions while C. difficile requires contact precautions for prevention.
Option d is incorrect because alcohol sanitizers don't kill C. difficile spores; soap and water handwashing is required for removal.

Correct Answer: Tighten muscles without moving

Isometric exercises involve muscle contraction without joint movement, maintaining strength during immobility while protecting healing tissues effectively.
Option a is incorrect because joint movement describes isotonic or range of motion exercises, not the static contractions of isometrics.
Option c is incorrect because weight lifting involves movement against resistance, not the stationary muscle contractions of isometric exercises prescribed.
Option d is incorrect because stretching involves lengthening muscles and moving joints rather than the static contractions isometric exercises provide.

Correct Answer: Maintain oral moisture comfort

Oral comfort through moisture maintenance respects patient autonomy while providing comfort care appropriate for terminal patients refusing nutrition.
Option a is incorrect because convincing violates patient autonomy and may cause distress when terminal patients choose to refuse eating.
Option c is incorrect because detailed documentation becomes less important than comfort measures when terminal patients refuse nutritional intake voluntarily.
Option d is incorrect because offering supplements contradicts patient wishes and comfort-focused care appropriate for terminal illness management approaches.

Correct Answer: Prongs curved upward incorrectly

Upward-curved prongs direct oxygen away from nasal passages, reducing therapeutic effectiveness and requiring repositioning for proper delivery.
Option a is incorrect because mouth breathing is common and doesn't prevent nasal oxygen delivery when cannula is properly positioned overall.
Option b is incorrect because tubing should go over, not behind ears, but this describes the observation needing correction identified.
Option d is incorrect because absence of condensation is normal and doesn't indicate problems with oxygen delivery through the cannula.

Correct Answer: Blister or shallow ulcer

Stage two pressure ulcers present as blisters or shallow open wounds involving epidermis and dermis layers without deeper exposure.
Option a is incorrect because intact red skin describes stage one pressure injury without the skin breakdown of stage two ulcers.
Option c is incorrect because visible fat indicates stage three pressure ulcer with full thickness skin loss beyond stage two involvement.
Option d is incorrect because exposed muscle indicates stage four pressure ulcer with extensive deep tissue damage beyond stage two.

Correct Answer: Do not aspirate syringe

Avoiding aspiration prevents tissue trauma and hematoma formation when injecting anticoagulants into subcutaneous tissue with fragile capillaries present.
Option a is incorrect because massaging spreads anticoagulant and traumatizes tissue, significantly increasing bruising and hematoma formation at sites.
Option b is incorrect because ice causes vasoconstriction that may affect medication absorption and doesn't prevent bruising from occurring.
Option d is incorrect because deltoid muscle isn't appropriate for subcutaneous heparin; abdominal and thigh sites are preferred locations.