D439 Foundations of Nursing - Set 1 - Part 3

Correct Answer: Reaching over sterile field

Reaching over the sterile field risks dropping contaminants from arms or clothing, breaking sterility and requiring field replacement.
Option a is incorrect because opening packages away from yourself first is correct technique preventing contamination of the sterile field.
Option b is incorrect because keeping hands above waist maintains sterility by preventing contact with non-sterile areas below waist level.
Option d is incorrect because maintaining one-inch non-sterile border is correct technique providing safe handling area without contamination risk.

Correct Answer: Elevated blood glucose levels

Nocturia in diabetics typically indicates hyperglycemia causing osmotic diuresis as kidneys attempt to excrete excess glucose overnight.
Option a is incorrect because while UTIs cause frequency, nocturia specifically in diabetics more commonly indicates poor glucose control.
Option b is incorrect because prostate enlargement affects older males specifically, while diabetic nocturia occurs regardless of gender factors.
Option d is incorrect because decreased kidney function would reduce urine output rather than increase nighttime urination frequency typically observed.

Correct Answer: Irregular apical pulse rhythm

Irregular pulse rhythm indicates cardiac dysrhythmias from potassium imbalance requiring immediate intervention to prevent cardiac arrest potentially.
Option a is incorrect because while muscle weakness occurs with potassium imbalance, it doesn't pose immediate life-threatening risk requiring priority.
Option c is incorrect because decreased bowel sounds indicate slowed motility but don't represent immediate life-threatening complications from imbalance.
Option d is incorrect because cognitive changes are concerning but cardiac rhythm disturbances take priority for immediate intervention needs.

Correct Answer: Against medical advice form

AMA forms document that patients were informed of risks but chose to leave, protecting healthcare providers from liability.
Option a is incorrect because incident reports document unexpected events, not patient's informed decision to refuse treatment and leave.
Option c is incorrect because restraint orders cannot be used to prevent competent adults from leaving against medical advice legally.
Option d is incorrect because psychiatric transfer isn't indicated solely for refusing treatment unless mental competency concerns exist independently.

Correct Answer: Clean with back forth

Back and forth cleansing motions of the meatus after foreskin retraction effectively removes contaminants while maintaining sterile technique.
Option a is incorrect because circular cleansing may recontaminate cleaned areas by bringing dirty solution back over clean tissue.
Option c is incorrect because leaving foreskin in place prevents proper meatus visualization and cleansing necessary for sterile insertion.
Option d is incorrect because single cleansing is insufficient for removing contaminants that could cause urinary tract infection development.

Correct Answer: Notify surgeon and anesthesiologist

Surgical team notification ensures all providers understand resuscitation preferences before proceeding with surgery requiring immediate code status clarification.
Option a is incorrect because surgery cancellation isn't automatic; the team must discuss options with patient for informed decision-making.
Option b is incorrect because documentation alone doesn't ensure surgical team awareness of critical resuscitation status preferences before proceeding.
Option d is incorrect because while DNR documentation is important, immediate surgical team notification takes priority for today's procedure.

Correct Answer: Clear lung sounds bilaterally

Clear lung sounds indicate successful fluid removal from pulmonary circulation, showing effective diuresis for fluid volume excess.
Option a is incorrect because respiratory rate changes don't specifically indicate fluid removal success compared to lung sound improvement.
Option b is incorrect because increased blood pressure suggests continued fluid excess rather than successful diuresis achieving volume reduction.
Option d is incorrect because increasing peripheral edema indicates worsening fluid accumulation, not effective diuresis removing excess volume successfully.

Correct Answer: Have patient visualize positively

Positive visualization of calm places or successful outcomes activates relaxation responses, effectively reducing pre-procedure anxiety levels significantly.
Option a is incorrect because detailed procedure descriptions may increase rather than decrease anxiety, especially focusing on technical aspects.
Option c is incorrect because discussing complications heightens anxiety rather than using imagery techniques for relaxation and coping.
Option d is incorrect because reviewing past experiences may trigger negative memories rather than promoting positive visualization for anxiety reduction.

Correct Answer: Dextrose ten percent water

Ten to twenty percent dextrose prevents hypoglycemia when TPN is interrupted while awaiting new bag availability for continuation.
Option a is incorrect because normal saline lacks glucose, risking severe hypoglycemia when transitioning from high-glucose parenteral nutrition suddenly.
Option c is incorrect because lactated ringers doesn't provide adequate glucose to prevent hypoglycemia during parenteral nutrition interruption periods.
Option d is incorrect because stopping completely causes dangerous hypoglycemia from sudden cessation of high glucose parenteral nutrition delivery.

Correct Answer: I'll press inner corner

Pressing the inner corner performs punctal occlusion, preventing systemic absorption while maximizing local therapeutic effect for glaucoma treatment.
Option a is incorrect because rapid blinking causes medication loss from the eye, reducing therapeutic effectiveness of glaucoma treatment significantly.
Option c is incorrect because rubbing disturbs medication distribution and may cause irritation or contamination of the treated eye.
Option d is incorrect because forward tilting causes medication to drain out rather than remaining in contact with eye tissues.