Foundations of Nursing (PNR 106)

The correct answer is A: 15 to 20 minutes on, then 15 to 20 minutes off

Explanation:

When applying hot or cold compresses, it is recommended to apply them for 15 to 20 minutes at a time. After this duration, the compress should be removed, and a rest period of 15 to 20 minutes off is advised. This cycle allows the body to respond appropriately to the temperature changes without causing tissue damage.

Why the Other Options Are Incorrect

B. 30 to 60 minutes on, then 30 to 60 minutes off:

This is incorrect because prolonged application of hot or cold compresses for extended periods (30 to 60 minutes) can lead to skin damage or cause adverse effects such as frostbite or burns.

C. 10 to 15 minutes on, then 30 minutes off:

This is not the best option because the recommended duration for hot and cold compresses is generally 15 to 20 minutes on, with equal rest time off, not just 10 to 15 minutes, and a 30-minute rest period is too long compared to the 15 to 20-minute off time.

D. 5 to 10 minutes on, then 5 to 10 minutes off:

This duration is too short to achieve the desired therapeutic effect of heat or cold compresses. A longer duration is recommended to provide adequate relief and allow time for the body to respond.

Summary:

When using hot or cold compresses, apply the compress for 15 to 20 minutes, followed by a 15 to 20-minute rest period. This cycle ensures therapeutic benefits while minimizing the risk of adverse effects.

The correct answer is C: Auscultate the lungs for adventitious breath sounds

Explanation:

Auscultation of the lungs is the most effective assessment technique to determine the need for suctioning. When secretions accumulate in the airway, they can cause adventitious breath sounds, such as coarse crackles, rhonchi, or diminished breath sounds, indicating partial airway obstruction. If these abnormal sounds are present, suctioning may be necessary to clear the airway and improve gas exchange.

Why the Other Options Are Incorrect:

A. Ask the patient if they feel they need suctioning:

While some patients may report difficulty breathing or feeling "clogged," not all patients can effectively communicate their needs, especially if they are intubated, sedated, or nonverbal. Objective assessment techniques, such as auscultation, provide a more reliable indicator of the need for suctioning.

B. Measure the patient’s oxygen saturation level:

Low oxygen saturation (SpO₂ below 90%) can indicate inadequate ventilation, but it is a late sign of secretion buildup. By the time oxygen levels drop, the patient may already be in distress. Early assessment with auscultation allows for proactive suctioning before hypoxia develops.

D. Observe for signs of tachypnea and respiratory distress:

While tachypnea, use of accessory muscles, or nasal flaring can indicate respiratory distress, these signs do not specifically confirm secretion buildup. Respiratory distress can result from many causes, including bronchospasm or worsening pulmonary disease. Auscultation provides direct evidence of airway obstruction due to secretions.

Summary:

The best technique to determine if a tracheostomy patient requires suctioning is auscultating the lungs for adventitious breath sounds like crackles or rhonchi. While patient complaints, oxygen saturation, and signs of respiratory distress provide additional clues, they are less reliable than auscultation, which allows for early detection and timely intervention. Suctioning should only be performed when clinically indicated to prevent unnecessary irritation, trauma, and hypoxia.

The correct answer is C: Vegan

Explanation:

A vegan diet excludes all animal-derived food products, including meat, dairy, eggs, and even honey. The term "vegan" refers to a lifestyle and dietary choice that avoids all animal products for ethical, environmental, or health reasons. Therefore, a person who follows a vegan diet does not consume honey, as it is produced by bees.

Why the Other Options Are Incorrect:

A. Race:

Race refers to physical characteristics and social categories, typically related to a person's biological attributes such as skin color or genetic lineage. It does not describe dietary restrictions or preferences.

B. Spirituality:

Spirituality refers to the beliefs and practices related to one's sense of connection to a higher power or purpose. While some spiritual practices may involve dietary restrictions, "spirituality" does not specifically refer to the exclusion of animal products like honey.

D. Cultural relativism:

Cultural relativism is the belief that a person's values, beliefs, and practices should be understood in the context of their own culture, without judgment. It is a concept used to understand different cultural norms but does not specifically address dietary practices like veganism.

Summary:

The correct matching term for the exclusion of all animal food sources, including honey, is vegan. Veganism specifically excludes all animal products from the diet, which aligns with the description provided.

The correct answers are:

A) Check blood glucose levels regularly, especially when feeling unwell

C) Carry candy or glucose tablets in their wallet to treat hypoglycemia

E) Consume low glycemic index foods to help maintain stable blood sugar levels

Explanation:

Option A is correct: Regularly checking blood glucose levels is essential for managing Type 1 diabetes. This is especially important when the patient feels unwell, as illness can affect blood sugar levels.

Option C is correct: Having quick sources of sugar, like candy or glucose tablets, on hand is critical for treating hypoglycemia (low blood sugar).

Option E is correct: Eating foods with a low glycemic index helps maintain stable blood sugar levels and is beneficial for diabetes management.

Why the Other Options Are Incorrect:

Option B is incorrect: Foods with a high glycemic index can cause rapid spikes in blood sugar, which is not ideal for diabetes management.

Option D is incorrect: It is important to check blood glucose levels when feeling unwell, as this can help prevent dangerous fluctuations in blood sugar.

Summary:

To effectively manage Type 1 diabetes, patients should regularly check blood glucose levels, carry glucose tablets or candy to treat hypoglycemia, and focus on consuming low glycemic index foods to keep their blood sugar stable.

The correct answer is B: Stop the procedure and begin with a new sterile kit

Explanation:

If a nurse accidentally inserts the urinary catheter into the vagina instead of the urethra, the correct response is to stop the procedure immediately. The nurse should then discard the contaminated catheter and begin with a new sterile kit. This ensures that the procedure is still performed under sterile conditions, reducing the risk of infection.

Inserting the catheter into the vagina introduces contamination, and continuing with the same sterile kit after such a mistake would compromise the sterility of the procedure. It is important to ensure that the catheterization is done using a fresh, sterile kit to avoid introducing any harmful bacteria into the urinary tract.

Why the Other Options Are Incorrect:

A. Continue with the procedure using the same sterile kit:

This is incorrect because inserting the catheter into the vagina introduces contamination. Continuing with the same sterile kit would compromise sterility and increase the risk of infection. The catheter should be discarded and a new sterile kit should be used.

C. Insert the catheter through the vaginal opening:

This is also incorrect because the urinary catheter should never be inserted through the vaginal opening. The correct site is the urethra. Inserting the catheter into the vagina would not provide access to the urinary tract and could lead to trauma and infection.

D. Attempt to clean the catheter and continue the insertion:

This is incorrect because cleaning the contaminated catheter does not restore its sterility. Once the catheter has been contaminated by the vaginal opening, it should be discarded, and a new sterile kit should be used to ensure a proper and sterile procedure.

Summary

If a nurse accidentally inserts the urinary catheter into the vagina, the correct response is to stop the procedure immediately, discard the contaminated catheter, and begin with a new sterile kit. This ensures the procedure is safe, sterile, and reduces the risk of infection.

The correct answer is A: Leukopenia

Explanation:

Leukopenia is a condition characterized by a low white blood cell (WBC) count. White blood cells are crucial for the immune system’s ability to fight infections, and when the WBC count is low, the body’s ability to defend against pathogens is compromised. Leukopenia can be caused by various factors, including viral infections, certain medications, chemotherapy, and bone marrow disorders.

Why the Other Options Are Incorrect:

B. Leukocytosis:

Leukocytosis refers to an elevated white blood cell count, typically indicating an ongoing infection or inflammation in the body. This is the opposite of leukopenia.

C. Thrombocytopenia:

Thrombocytopenia is a condition characterized by a low platelet count, not a low white blood cell count. Platelets are essential for blood clotting.

D. Anemia:

Anemia refers to a low red blood cell count, which affects the ability to carry oxygen in the blood. It is unrelated to the white blood cell count.

Summary:

Leukopenia refers to a low white blood cell count, which can impair the body’s ability to fight infections. It is important for healthcare providers to monitor patients with leukopenia for signs of infection and take appropriate precautions.

The correct answers are:

A) Ensure the Hemovac is compressed

B) Check the Hemovac for any signs of infection or leakage

D) Measure the amount of drainage and document it

Explanation:

After surgery, a Hemovac drain is used to remove excess fluid and prevent blood clots from forming at the surgical site. To ensure proper function, you need to conduct several assessments:

Ensure the Hemovac is compressed (A): For the Hemovac to work correctly, it must be compressed to create a vacuum that draws fluid into the drain. If the Hemovac is not compressed, it will not adequately remove fluid from the surgical area. Check to ensure that it is fully compressed and maintains suction.

Check the Hemovac for signs of infection or leakage (B): Inspect the drain and surrounding area for any signs of infection, such as redness, warmth, swelling, or discharge, and check for leakage. Leakage could indicate a break in the drain or a problem with the insertion site.

Measure the amount of drainage and document it (D): Regularly measuring and documenting the amount of drainage is essential for assessing the progress of the patient’s recovery. Excessive drainage may indicate complications like bleeding or fluid accumulation.

Why the Other Options Are Incorrect:

C) Assess the patient's pain level: While the patient's pain level should be assessed as part of overall care, it is not specific to the Hemovac drain's functioning. The focus here should be on ensuring the drain is working properly.

E) Administer the prescribed antibiotics: Administering antibiotics is important if there are signs of infection, but this is not a step specific to ensuring the Hemovac is functioning. The drain should first be checked for infection signs to determine the need for antibiotics.

F) Apply heat to the surgical site: Applying heat is generally not recommended with a drain in place as it could increase the risk of bleeding or infection. Cold compresses are sometimes used, but heat is contraindicated unless prescribed by the healthcare provider.

Summary:

When caring for a patient with a Hemovac drain post-surgery, the nurse should ensure that the Hemovac is properly compressed to create suction, check for any signs of infection or leakage, and monitor the amount of drainage. Regular assessment of these factors will help ensure that the drain is functioning properly and reduce the risk of complications.

The correct answer isA :Appendectomy

Explanation:

The suffix “-ectomy” refers to the surgical removal of a body part. In this case, the procedure being performed is the removal of the appendix, which is correctly termed "appendectomy." The nurse should be familiar with medical terminology to ensure clear communication with the surgical team and the patient.

Why the Other Options Are Incorrect:

B. Laparotomy

This is incorrect because a laparotomy is a surgical procedure involving an incision into the abdomen, typically for diagnostic or exploratory purposes, not for the removal of a specific organ like the appendix.

C. Colostomy

This is incorrect because a colostomy is a surgical procedure in which a portion of the colon is diverted to an opening in the abdomen, creating an external pouch for waste. It is not related to the removal of the appendix.

D. Gastrectomy

This is incorrect because a gastrectomy refers to the surgical removal of all or part of the stomach, not the appendix.

Summary:

The correct medical term for the surgical removal of the appendix is "appendectomy," which is indicated by the suffix “-ectomy,” meaning to cut out or remove.

The correct answer is B: The belief that one’s own cultural group determines the standards by which other groups' behavior should be judged

Explanation:

Ethnocentrism refers to the belief that one's own culture or ethnic group is superior to others and serves as the standard by which other cultures or behaviors should be judged. This can lead to biases and misunderstandings when interacting with people from different cultural backgrounds. In healthcare, ethnocentrism can affect patient care by promoting cultural insensitivity, which may result in unequal treatment.

Why the Other Options Are Incorrect:

A. The belief that all cultures are equal and should be treated with the same respect:

 This describes cultural relativism, which is the opposite of ethnocentrism. It promotes understanding and respecting cultural differences without making judgments based on one’s own cultural norms. 

C. The process of adapting to and adopting the cultural traits or social patterns of another group:

This describes assimilation or acculturation, where individuals or groups adopt the cultural practices of another group, often in the context of immigration or cultural exchange.

D. The practice of learning about and understanding other cultures to improve healthcare delivery:

This describes cultural competence, which involves healthcare professionals learning about and understanding different cultures to provide effective, respectful care to all patients.

Summary:

Ethnocentrism is the belief that one’s own cultural group sets the standard by which other cultures should be judged. This perspective can hinder cultural understanding and respect, especially in healthcare settings where cultural sensitivity is crucial to providing equitable care.