D439 Foundations of Nursing - Set 3 - Part 3

Correct Answer: Imagine peaceful safe places

Visualizing peaceful places activates relaxation responses that reduce pain perception through distraction and stress reduction mechanisms naturally.
Option a is incorrect because focusing on pain location intensifies awareness and perception rather than providing relief through distraction techniques.
Option c is incorrect because counting is a different technique that doesn't involve the visualization component of guided imagery specifically.
Option d is incorrect because muscle tensing describes progressive muscle relaxation, not the mental imagery technique for pain management.

Correct Answer: Coughing during formula infusion

Coughing during feeding suggests formula entering airway from displaced tube, requiring immediate verification to prevent aspiration pneumonia development.
Option a is incorrect because comfort doesn't indicate proper placement as displaced tubes may not cause discomfort initially before complications.
Option b is incorrect because low residuals indicate good gastric emptying but don't confirm proper tube positioning for safe feeding.
Option d is incorrect because hunger is unrelated to tube placement and may occur despite adequate nutrition delivery through properly positioned tubes.

Correct Answer: Airborne and contact precautions

Varicella requires both airborne precautions for respiratory transmission and contact precautions for vesicle fluid transmission preventing spread effectively.
Option a is incorrect because contact alone doesn't prevent airborne transmission of varicella virus through respiratory droplet nuclei in air.
Option b is incorrect because droplet precautions don't protect against smaller airborne particles that transmit varicella over greater distances.
Option d is incorrect because standard precautions alone are insufficient for highly contagious varicella requiring additional transmission-based precautions implemented.

Correct Answer: Enter late entry later

Late entry documentation after system restoration maintains legal record continuity while ensuring all care is properly documented accurately.
Option a is incorrect because waiting delays documentation that should occur as close to care delivery as possible for accuracy.
Option b is incorrect because paper documentation may not integrate properly with electronic systems and creates transcription error risks.
Option d is incorrect because skipping documentation violates legal requirements and compromises patient safety through incomplete medical records maintained.

Correct Answer: Massages red areas vigorously

Vigorous massage of reddened areas damages fragile capillaries and tissues, worsening pressure injury rather than preventing ulcer formation.
Option a is incorrect because position changes every two hours appropriately redistributes pressure preventing tissue ischemia and breakdown development progressively.
Option c is incorrect because pressure redistribution mattresses appropriately reduce pressure on bony prominences helping prevent ulcer formation effectively.
Option d is incorrect because adequate protein supports tissue integrity and healing, representing appropriate pressure ulcer prevention knowledge demonstrated.

Correct Answer: Kidneys excrete excess glucose

High blood glucose causes osmotic diuresis as kidneys attempt to excrete excess glucose, pulling water and increasing urination frequency.
Option a is incorrect because while infections cause frequency, diabetic nocturia specifically results from hyperglycemia-induced osmotic diuresis, not infection necessarily.
Option c is incorrect because bladder weakness isn't the primary mechanism; osmotic diuresis from glucose excretion drives increased urination in diabetes.
Option d is incorrect because prostate issues affect older males specifically while diabetic nocturia affects all genders through metabolic mechanisms.

Correct Answer: Rotate pressure points regularly

Rotating pressure points through mask adjustment or different mask styles prevents concentrated pressure causing skin breakdown over time.
Option a is incorrect because loose straps compromise CPAP effectiveness for sleep apnea treatment while not preventing pressure injury development.
Option c is incorrect because hourly removal interrupts sleep and therapy effectiveness without providing adequate pressure relief for skin protection.
Option d is incorrect because thick creams may compromise mask seal and don't address the mechanical pressure causing skin breakdown fundamentally.

Correct Answer: White blood cell count

Decreasing white blood cell counts indicate infection resolution with effective antibiotics, while increasing counts suggest treatment failure requiring changes.
Option a is incorrect because hemoglobin and hematocrit reflect oxygen capacity and blood loss, not infection status or antibiotic effectiveness.
Option c is incorrect because platelets may react to inflammation but don't specifically indicate antibiotic effectiveness against bacterial infections directly.
Option d is incorrect because creatinine monitors kidney function which some antibiotics affect, but doesn't indicate infection treatment effectiveness.

Correct Answer: Tomato soup with milk

Tomato soup with milk contains opaque dairy products and vegetable solids that violate clear liquid diet restrictions completely.
Option a is incorrect because pulp-free cranberry juice is an acceptable clear liquid providing hydration and nutrients without residue present.
Option b is incorrect because clear beef broth without vegetables is a standard clear liquid providing electrolytes and minimal nutrition appropriately.
Option d is incorrect because plain lemon gelatin is a classic clear liquid that provides calories and fluid without residue.

Correct Answer: Create small raised bubble

Proper intradermal injection creates a characteristic wheal or bubble in the epidermis, confirming correct placement for tuberculin testing.
Option a is incorrect because forty-five degrees delivers medication subcutaneously rather than the superficial intradermal placement required for testing.
Option c is incorrect because massaging disperses the antigen preventing proper reaction formation needed for accurate tuberculin test reading.
Option d is incorrect because bandages aren't needed and may affect test results by creating pressure or moisture over injection site.