Adult Health Nursing Test Bank

Correct Answer: D

Rationale: The correct answer is D because confirming the insertion site and direction using imaging guidance ensures precise placement of the chest tube, minimizing the risk of complications. Imaging guidance allows the nurse to visualize the exact location of the pneumothorax and guide the tube insertion accurately. A: Positioning the patient in a semi-Fowler's position with arms elevated may be beneficial for comfort but does not directly ensure proper chest tube placement. B: Marking the insertion site with a pen may help as a reference point but does not guarantee accurate placement. C: Administering analgesia is important for the patient's comfort but does not impact the placement of the chest tube. In summary, choice D is the most critical step to ensure the chest tube is correctly placed and effectively treats the pneumothorax.

Correct Answer: C

Rationale: In a postpartum client who presents with severe abdominal pain, nausea, and vomiting, it is crucial to assess for signs of peritonitis or surgical abdomen. These signs may include rebound tenderness, guarding, rigidity, and fever. Peritonitis is a serious condition that may require immediate surgical intervention. Administering antiemetic medication, encouraging clear fluids, or providing a heating pad may not address the underlying cause of the symptoms and delay appropriate treatment. Assessing for signs of peritonitis or surgical abdomen is crucial for prompt identification and management of the client's condition.

Correct Answer: A

Rationale: The correct answer is A: Enhances the delivery of quality nursing care. Supervision and delegation are essential in ensuring efficient and effective healthcare delivery. By supervising and delegating tasks appropriately, the head nurse can ensure that staff members are performing their duties competently, which ultimately leads to improved quality of patient care. Supervision helps in monitoring staff performance, providing feedback, and offering guidance when needed. Delegation ensures that tasks are allocated to the right staff members based on their skills and abilities, optimizing the workflow. Choices B, C, and D are incorrect because they do not directly relate to the primary purpose of supervision and delegation, which is to enhance the quality of nursing care through effective oversight and task allocation.

Correct Answer: B

Rationale: The correct answer is B: Negligence. Negligence refers to the failure to exercise the care that a reasonably prudent person would under similar circumstances. In this case, administering the wrong dose of a vaccine indicates a lack of proper care or attention to detail, which constitutes negligence. A: Battery involves intentional harmful or offensive contact without consent, which is not applicable in this situation. C: Assault involves the threat of harm or unwanted physical contact, which is also not relevant here. D: Malpractice typically refers to professional misconduct or negligence by a healthcare provider, which could be a broader term but not specific to the situation described.

Correct Answer: A

Rationale: Demonstrating breastfeeding positions that minimize pressure on the incision site should be the nursing intervention prioritized to address the client's concerns. This is important because it ensures that the client can breastfeed comfortably while also protecting the healing incision. By showing the client appropriate positions, such as the football hold or side-lying position, the nurse can help minimize discomfort and promote successful breastfeeding without compromising the cesarean incision's healing process. It is crucial to support the client in establishing a good latch and positioning to encourage proper milk transfer and bonding while being mindful of the incision site.