D439 Foundations of Nursing - Set 5 - Part 2

Correct Answer: Clean from meatus outward

Cleaning from meatus outward prevents bringing contaminants toward the urethral opening where they could cause ascending urinary infections.
Option a is incorrect because circular motions may recontaminate cleaned areas by bringing dirty solution back over clean tissue surfaces repeatedly.
Option c is incorrect because back and forth motions risk spreading contamination rather than removing it systematically from the meatus area.
Option d is incorrect because starting outside brings contaminants toward the meatus rather than away, increasing infection risk significantly present.

Correct Answer: Control blood glucose levels

Controlling hyperglycemia reduces osmotic diuresis that causes excessive urination, addressing the root cause of diabetic nocturia effectively managed.
Option a is incorrect because fluid restriction doesn't address hyperglycemia causing osmotic diuresis and may lead to dehydration complications developing unnecessarily.
Option c is incorrect because bedtime diuretics worsen nocturia rather than improving it, contradicting therapeutic goals for symptom management needed.
Option d is incorrect because frequent emptying doesn't address the underlying hyperglycemia driving increased urine production causing nocturia symptoms experienced nightly.

Correct Answer: Replace entire sterile field

Any contamination of sterile field requires complete replacement as sterility cannot be restored once compromised, ensuring patient safety maintained.
Option a is incorrect because continuing with contaminated field risks infection regardless of caution level exercised during the procedure subsequently performed.
Option b is incorrect because marking doesn't restore sterility; the entire field is compromised once any contamination occurs requiring replacement immediately needed.
Option d is incorrect because covering contamination doesn't eliminate it; bacteria can still spread throughout the field causing infection risk.

Correct Answer: Canned soup and vegetables

Canned products contain high sodium levels that promote fluid retention, worsening heart failure symptoms and increasing cardiac workload significantly experienced.
Option a is incorrect because fresh produce provides nutrients without excessive sodium, supporting heart health when managing failure symptoms appropriately controlled effectively.
Option c is incorrect because lean protein supports nutrition without the high sodium content that worsens fluid retention in heart failure.
Option d is incorrect because whole grains provide beneficial fiber and nutrients without excessive sodium that exacerbates heart failure symptoms typically.

Correct Answer: Clear bilateral lung sounds

Clear lung sounds indicate successful fluid removal from pulmonary circulation, the primary goal when treating life-threatening pulmonary edema immediately.
Option a is incorrect because while increased output shows diuresis occurring, it doesn't confirm pulmonary fluid clearance specifically achieved therapeutically needed urgently.
Option c is incorrect because peripheral edema reduction is positive but less critical than clearing pulmonary fluid threatening respiratory function immediately present.
Option d is incorrect because blood pressure changes don't specifically indicate pulmonary fluid status improvement requiring priority assessment for safety verified.

Correct Answer: Patient's skin color changes

Skin color changes indicate oxygenation status and developing hypoxia requiring immediate intervention to prevent complications during suctioning procedures performed.
Option a is incorrect because canister level is important but doesn't indicate patient tolerance or oxygenation status during the procedure itself.
Option c is incorrect because while depth matters for safety, continuous monitoring of patient response takes priority over measuring catheter depth.
Option d is incorrect because pressure readings indicate equipment function but don't reflect patient's physiological response to suctioning occurring currently performed.

Correct Answer: Supine position with head flat

Supine positioning allows fluid pooling in pharynx causing aspiration, making it contraindicated for unconscious patients receiving oral care.
Option a is incorrect because side-lying position appropriately promotes drainage preventing aspiration, making it recommended rather than contraindicated for safety ensured.
Option b is incorrect because bedside suction is essential safety equipment for managing secretions during oral care of unconscious patients appropriately.
Option d is incorrect because soft toothbrushes are appropriate for gentle cleaning without trauma, not contraindicated for unconscious patient care provided.

Correct Answer: Visualize peaceful scenes mentally

Mental visualization of calming scenes activates relaxation responses that reduce pain perception through distraction and stress reduction naturally achieved.
Option a is incorrect because focusing on pain intensifies perception rather than providing the distraction and relief guided imagery offers therapeutically.
Option c is incorrect because breath counting is a different relaxation technique, not the visualization component of guided imagery specifically utilized.
Option d is incorrect because muscle tensing and releasing describes progressive muscle relaxation, not the mental imagery technique being discussed currently.

Correct Answer: Skips doses when not eating

Skipping insulin doses causes dangerous hyperglycemia regardless of food intake, requiring re-education about consistent administration for glucose control maintained.
Option a is incorrect because site rotation prevents lipodystrophy and ensures consistent absorption, indicating proper technique understanding demonstrated appropriately by patient.
Option b is incorrect because refrigeration maintains insulin potency, showing correct storage knowledge though room temperature storage is also acceptable alternatively.
Option d is incorrect because regular monitoring helps guide insulin adjustments and identifies problems, demonstrating good self-management practices followed consistently overall.

Correct Answer: Ninety-degree upright position

Ninety-degree positioning maximizes gravity assistance preventing reflux and aspiration in high-risk patients during feeding administration safely provided continuously.
Option a is incorrect because flat positioning allows reflux and aspiration, making it dangerous for any patient receiving enteral feedings administered.
Option b is incorrect because thirty degrees provides insufficient elevation for high-risk patients though adequate for standard aspiration precautions typically recommended.
Option c is incorrect because sixty degrees offers moderate protection but ninety degrees provides maximum safety for high-risk aspiration patients specifically.

Correct Answer: Sample from deepest area

Deep sampling obtains organisms causing infection rather than surface contaminants, providing accurate culture results for appropriate antibiotic selection made.
Option a is incorrect because cleaning removes organisms needed for culture identification, potentially leading to false negative results and inappropriate treatment.
Option b is incorrect because wound edges contain surface contaminants rather than causative organisms present deeper within infected tissue areas sampled.
Option d is incorrect because sterile technique is required to prevent contamination that would produce inaccurate culture results affecting treatment decisions.

Correct Answer: Secure to side rails

Rail attachment causes dangerous restraint tightening or loosening when rails move, requiring attachment to stable bed frame instead always.
Option a is incorrect because fifteen-minute circulation checks are appropriate initial monitoring to prevent tissue damage from tight restraints applied incorrectly.
Option b is incorrect because bed frame attachment is correct technique ensuring restraints remain properly positioned regardless of rail adjustments made subsequently.
Option c is incorrect because slip knots are correct, allowing quick release in emergencies while maintaining secure restraint when needed appropriately utilized.

Correct Answer: Diabetes insipidus possibly developing

Extremely low specific gravity indicates inability to concentrate urine, characteristic of diabetes insipidus requiring further evaluation and treatment immediately.
Option a is incorrect because normal specific gravity ranges from one point zero zero five to one point zero three zero typically expected.
Option b is incorrect because dehydration causes high specific gravity from concentrated urine, not the dilute urine indicated by low values.
Option d is incorrect because urinary infections don't specifically affect specific gravity unless kidney function is significantly compromised by infection spreading.

Correct Answer: Independent decisions are allowed

Competent adults make independent advance directive decisions without requiring family agreement, maintaining autonomy over their healthcare wishes expressed legally.
Option a is incorrect because family approval isn't legally required for competent adults creating advance directives about their own care preferences stated.
Option c is incorrect because court involvement isn't needed for advance directives unless competency questions exist requiring legal determination of capacity assessed.
Option d is incorrect because physician approval isn't required though medical input may help inform decisions about treatment options available potentially considered.

Correct Answer: Positioning at sixty degrees

Sixty-degree elevation is insufficient for high aspiration risk patients who require ninety-degree positioning for maximum protection during feeding safely.
Option a is incorrect because ninety-degree elevation is correct positioning for aspiration prevention, not requiring correction or intervention from nurse supervising.
Option c is incorrect because careful oral care is appropriate though UAPs shouldn't perform this on high-risk patients without supervision provided.
Option d is incorrect because while UAPs shouldn't check tube placement, this awareness of importance shows good understanding of safety principles involved.

Correct Answer: Accessory muscle use visible

Accessory muscle recruitment indicates respiratory distress when normal diaphragmatic breathing cannot meet oxygenation demands, requiring immediate assessment and intervention provided.
Option a is incorrect because regular patterns indicate normal breathing without the increased effort that would require nursing intervention immediately needed urgently.
Option b is incorrect because diaphragmatic breathing is normal and efficient, not indicating increased work requiring intervention or additional support provided.
Option d is incorrect because sixteen breaths per minute falls within normal adult range, not indicating increased respiratory work or distress present.

Correct Answer: Intact red skin present

Stage one pressure injuries present as intact skin with non-blanchable redness, without the skin breakdown of more advanced stages developed.
Option a is incorrect because skin breakdown indicates at least stage two pressure injury, not the intact skin of stage one described.
Option c is incorrect because visible fat indicates stage three pressure ulcer with full thickness skin loss, beyond stage one involvement shown.
Option d is incorrect because muscle and bone exposure indicates stage four pressure ulcer, the most severe classification of pressure injuries possible.

Correct Answer: Cool dark room environment

Cool, dark environments promote melatonin production and prevent sensory disruption, facilitating natural sleep without pharmaceutical interventions needed for rest.
Option a is incorrect because television noise and light stimulate the brain, preventing deep restorative sleep cycles from occurring naturally overnight.
Option b is incorrect because bright lights suppress melatonin and disrupt circadian rhythms essential for quality sleep patterns maintained consistently throughout.
Option d is incorrect because hourly interruptions fragment sleep preventing restorative rest, worsening rather than promoting healthy sleep patterns naturally achieved.

Correct Answer: Hold feeding notify physician

Residuals over five hundred milliliters indicate delayed gastric emptying requiring medical evaluation before continuing feeds to prevent aspiration risk.
Option a is incorrect because returning large residuals and continuing feeds risks aspiration from overfilled stomach with poor motility demonstrated clearly present.
Option b is incorrect because discarding doesn't address the underlying problem of delayed emptying requiring medical assessment and intervention immediately needed urgently.
Option d is incorrect because dilution doesn't resolve high residual volumes and may worsen gastric distention increasing aspiration risk significantly elevated already.

Correct Answer: Two inches below armpits

Two-inch clearance prevents nerve and vessel compression while providing appropriate support, preventing permanent damage from improper crutch use occurring.
Option a is incorrect because armpit level contact causes nerve compression leading to permanent damage potentially developing with continued use improperly fitted.
Option c is incorrect because four-inch clearance provides insufficient support compromising stability and safety during non-weight bearing ambulation attempted regularly performed.
Option d is incorrect because snug armpit contact compresses nerves and vessels causing numbness, weakness, and potential permanent injury progressively developing increasingly.