Correct Answer: A

Rationale: Using a Foley catheter can help prevent skin breakdown caused by prolonged contact with urine in incontinent patients, especially if they are confused or non-ambulatory and unable to use other urinary devices. Maintaining intact skin is crucial to avoiding infections and pressure injuries, making a Foley catheter a suitable intervention in specific cases when prescribed. Foley catheters are not inherently inappropriate but must be prescribed judiciously due to risks like urinary tract infections. While alternative methods may be preferable, this intervention is justified for incontinent, immobile patients with compromised mental status to protect skin integrity. It aligns with clinical guidelines and patient-specific needs.

Correct Answer: A:D,B:B,C:E,D:A,E:C

Rationale: Osteomalacia matches choice D: It is caused by a vitamin D deficiency, leading to reduced calcium absorption, softening bones, and increasing fracture risk, uncommon in developed countries due to dietary fortification. Low back pain matches choice B: It is commonly due to musculoskeletal issues like muscle strain or disc problems and can present as localized or diffuse pain. Osteomyelitis matches choice E: It is a severe bacterial infection affecting bone and surrounding tissues, often requiring prolonged antibiotic therapy. Osteoporosis matches choice A: It is a chronic condition characterized by low bone mass and structural deterioration, increasing fragility and fracture risk, especially in postmenopausal women. Degenerative disc disease (DD
D) matches choice C: It involves age-related loss of disc fluid, reducing elasticity and shock absorption, contributing to back pain and spinal issues.

Correct Answer: A,C,D,F

Rationale: Performing neurovascular assessments on the affected extremity helps identify potential complications such as ischemia or nerve damage. This includes checking circulation, sensation, and movement regularly to ensure proper function and prevent permanent injury. Skeletal traction relies on the tension created by weights hanging freely to maintain proper alignment of the bone. If weights lay flat on the ground, the traction effect is lost, undermining the therapeutic purpose of the intervention. Observing pin sites for signs of infection is crucial in preventing complications like osteomyelitis. Regular monitoring ensures early detection and management of redness, swelling, or discharge, which can compromise treatment outcomes. Assessing skin for signs of breakdown is essential in immobile patients receiving skeletal traction. Prolonged pressure and reduced mobility increase the risk of pressure ulcers, necessitating vigilant skin checks and preventive measures. Applying a boot directly to the skin is not appropriate in skeletal traction. Devices must be used correctly and securely without creating additional pressure points or compromising the treatment's effectiveness. Providing pin site care prevents infections and maintains the integrity of the pin and surrounding tissue. This involves cleaning the area and using antiseptics, which are standard practices in skeletal traction care.

Correct Answer: C

Rationale: Administering 1 mg of glucagon intramuscularly is unnecessary for a patient who is awake, alert, and able to swallow. Glucagon is reserved for patients who are unconscious and unable to swallow effectively to prevent choking. Administering 25 g of dextrose IVP is unnecessary in this case because the patient is alert and able to swallow. Oral intake of carbohydrates is the preferred and safer intervention for mild hypoglycemia like 69 mg/dL. Holding the insulin and encouraging the patient to eat provides glucose through dietary means, which is appropriate in a patient who is awake, alert, and hungry. A level of 69 mg/dL, though below normal, can be managed with oral glucose intake safely. Calling the MD is not the immediate priority in managing mild hypoglycemia. Intervening directly to correct the glucose level with oral intake is more appropriate and effective in this situation.

Correct Answer: A

Rationale: Assisting the patient to the bathroom is within the scope of practice for a Nursing Aide (N
A) and does not require advanced training, making it an appropriate task to delegate while ensuring patient needs are met. Teaching weight-bearing precautions involves patient education, which is the responsibility of the Registered Nurse (RN) due to the need for professional judgment and instruction clarity. Pain level assessment requires critical thinking and professional judgment, which are within the RN's scope of practice. This cannot be delegated to an NA. Instruction on incentive spirometer use requires understanding of therapeutic goals, patient capability, and respiratory assessment, tasks specific to the RN and beyond the scope of an NA.