D439 Foundations of Nursing - Set 2 - Part 3

Correct Answer: Use everyday language consistently

Everyday language ensures understanding without being condescending, respecting older adults' intelligence while avoiding confusing medical terminology unnecessarily.
Option a is incorrect because assuming hearing loss and speaking loudly is disrespectful unless hearing impairment is confirmed present.
Option c is incorrect because limiting information assumes cognitive impairment inappropriately; older adults deserve complete information about their health.
Option d is incorrect because older adults maintain autonomy for health decisions unless specifically lacking capacity requiring surrogate decision-makers.

Correct Answer: Apply protective padding strategically

Strategic padding at pressure points prevents further skin breakdown while maintaining necessary tube placement for nutrition delivery.
Option a is incorrect because removing the tube eliminates nutrition delivery when padding could prevent damage while maintaining feeding access.
Option b is incorrect because frequent repositioning may worsen irritation and doesn't address the pressure causing skin breakdown directly.
Option d is incorrect because feeding volume doesn't affect tube pressure on skin; mechanical protection is needed at contact points.

Correct Answer: Twenty milliliters hourly output

Output below thirty milliliters hourly indicates potential kidney dysfunction or obstruction requiring immediate assessment and intervention to prevent damage.
Option a is incorrect because clear yellow urine indicates normal hydration and kidney function without signs of infection or complications.
Option b is incorrect because thirty milliliters hourly represents minimum adequate output indicating normal kidney function and perfusion status.
Option d is incorrect because absence of discomfort is expected with properly functioning catheters and doesn't indicate complications developing.

Correct Answer: Start with less sensitive questions

Beginning with less sensitive questions builds rapport and comfort before progressing to more intimate sexual health topics naturally.
Option a is incorrect because starting with intimate details may cause discomfort and communication shutdown before establishing therapeutic rapport effectively.
Option b is incorrect because medical terminology may confuse or distance patients; clear, comfortable language promotes better communication about sexuality.
Option d is incorrect because spouse presence may be supportive; patient preference should guide who remains during sensitive discussions appropriately.

Correct Answer: Canned soup with crackers

Canned soup contains high sodium levels that worsen fluid retention in patients with volume excess requiring dietary restriction.
Option a is incorrect because fresh fruits provide potassium and nutrients without excessive sodium that would worsen fluid retention problems.
Option c is incorrect because plain grilled chicken provides protein without added sodium that would exacerbate fluid volume excess.
Option d is incorrect because steamed vegetables without salt are ideal for fluid-restricted diets, providing nutrition without sodium.

Correct Answer: This must be frustrating

Acknowledging frustration validates patient feelings and opens communication about concerns without minimizing their experience or offering premature solutions.
Option a is incorrect because promising improvement dismisses current frustration and may not reflect realistic recovery expectations for stroke patients.
Option c is incorrect because offering solutions before acknowledging emotions invalidates feelings and may seem dismissive of legitimate frustration expressed.
Option d is incorrect because taking over tasks reduces independence and doesn't address the emotional impact of functional limitations.

Correct Answer: Eight feet away minimum

Eight feet minimum distance from heat sources prevents dangerous pressure increases in oxygen cylinders that could cause explosion.
Option a is incorrect because three feet is insufficient distance from heat sources that could dangerously increase cylinder pressure over time.
Option b is incorrect because five feet doesn't provide adequate safety margin from heat sources per oxygen storage safety guidelines.
Option d is incorrect because while ten feet provides safety, eight feet is the minimum required distance for safe oxygen storage.

Correct Answer: Drainage bag touching floor

Floor contact contaminates drainage bags with pathogens that can ascend through the system causing urinary tract infections.
Option a is incorrect because clear drainage indicates normal urine without infection, not requiring intervention beyond routine catheter care.
Option b is incorrect because thigh securement prevents catheter movement and trauma, representing proper care technique, not a problem.
Option d is incorrect because absence of pain indicates proper catheter function and positioning without complications requiring intervention immediately.

Correct Answer: Change position every two

Position changes every two hours redistribute pressure preventing tissue ischemia and breakdown that causes pressure ulcer formation progressively.
Option a is incorrect because hourly lotion application is excessive and doesn't address pressure, the primary cause of ulcer development.
Option c is incorrect because massaging reddened areas can damage fragile tissues and worsen developing pressure injuries rather than preventing them.
Option d is incorrect because overly dry skin cracks and breaks down; balanced moisture is needed for skin integrity maintenance.

Correct Answer: I'll skip insulin at bedtime

Skipping insulin worsens hyperglycemia causing increased nocturia from osmotic diuresis as kidneys attempt glucose excretion, requiring re-education immediately.
Option a is incorrect because regular blood sugar monitoring helps identify hyperglycemia causing nocturia, indicating good understanding of management needs.
Option b is incorrect because limiting evening fluids reduces nighttime urination volume while maintaining adequate daily hydration for health.
Option d is incorrect because avoiding nighttime caffeine prevents its diuretic effect from worsening nocturia, showing appropriate understanding of management.