Adult Health Med Surg Nursing Test Banks

Correct Answer: B

Rationale: Documenting all care provided, including assessments and interventions, is the principle that should guide the nurse's documentation practices in the electronic health record (EHR). Comprehensive and accurate documentation is essential for ensuring continuity of care, communication among healthcare team members, and legal protection. By documenting all care provided, the nurse contributes to a complete and thorough picture of the patient's condition and treatment, facilitating safe and effective patient care. This principle also aligns with professional standards and regulatory requirements, emphasizing the importance of timely and complete documentation in the EHR.

Correct Answer: C

Rationale: After formulating and delimiting the research problem, the priority action would be to plan the research design of the study. This is crucial because the research design will outline the specific methods and procedures that Gloria will use to investigate the research problem and answer the research questions. Planning the research design involves determining the overall structure of the study, selecting the appropriate research methods, and outlining how data will be collected and analyzed. This step is essential for ensuring that the study is well-organized, rigorous, and will yield reliable results. Developing a solid research design early on will set a strong foundation for the rest of the research process.

Correct Answer: D

Rationale: Incompetent cervix refers to a weakened cervix that is unable to support the weight of the growing fetus, leading to painless cervical dilation and second-trimester pregnancy loss. In this condition, the cervix may dilate prematurely without contractions, resulting in a painless cervical dilation. The history of recurrent second-trimester losses, along with cervical dilation and absence of uterine contractions in the presenting pregnant woman, are characteristic of incompetent cervix. Prompt recognition and management with cerclage placement can help prevent further pregnancy losses in women with incompetent cervix.

Correct Answer: C

Rationale: Medico-legal charts are typically stored for a minimum of 10 years after the case is closed to ensure compliance with legal requirements and to provide a comprehensive record of the medical care provided. This duration allows for potential future reference, follow-up treatment, or legal purposes that may arise within the specified timeframe. It is important to maintain these records for an extended period to protect both the patient's rights and the healthcare provider's accountability. Additionally, storing medico-legal charts for 10 years aligns with standard retention practices in the healthcare industry.

Correct Answer: D

Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.