Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: A

Rationale: Administering intravenous fluids as ordered is the most appropriate nursing action for a postpartum client exhibiting signs of severe dehydration. Severe dehydration, as indicated by dry mucous membranes, decreased skin turgor, and oliguria, requires immediate intervention to restore fluid balance effectively. Intravenous fluids deliver fluids directly into the bloodstream, ensuring rapid rehydration and addressing the critical situation promptly. Offering oral rehydration solutions may not be sufficient to address severe dehydration, and providing education on fluid intake can be important for prevention but is not the immediate priority in this scenario. Notifying the healthcare provider is essential, but initiating intravenous fluids promptly is crucial in managing severe dehydration.

Correct Answer: D

Rationale: An advance directive is a legal document that specifies a person's healthcare preferences and instructions for medical treatment in the event they are unable to communicate their wishes. It typically includes decisions about life-sustaining treatments, resuscitation, and end-of-life care. In the scenario provided, the document provided by the patient to the nurse outlining his healthcare team's instructions postoperatively indicates that he has an advance directive in place to guide his medical care if necessary. In contrast, informed consent is a process in which a patient gives permission for medical treatment after being informed about the risks, benefits, and alternatives. Patient's Bill of Rights outlines the patient's rights within the healthcare system, and an insurance card provides information about the patient's insurance coverage.

Correct Answer: B

Rationale: The cardiovascular disorder most likely responsible for the symptoms described is a pericardial effusion. A pericardial effusion is an accumulation of fluid within the pericardial space surrounding the heart. When a large pericardial effusion is present, it can lead to compression of the heart chambers, resulting in symptoms such as chest pain and dyspnea.

Correct Answer: B

Rationale: Sunken fontanels are one of the earliest signs of dehydration in infants. Fontanels are soft spots on an infant's head where the skull bones have not yet fused together. If a baby's fontanel appears sunken, it indicates that the baby is likely dehydrated. This occurs because when there is a lack of fluid in the body, the soft spots on the head will appear depressed or sunken. It is crucial for Nurse Juvy to closely monitor the fontanels of Baby Sharon, as identifying dehydration early is essential for prompt intervention and preventing complications.

Correct Answer: C

Rationale: When selecting participants for a qualitative research study, it is important to choose individuals who are able to articulate and reflect on the phenomenon being studied. This is crucial for gathering in-depth and rich data that can provide valuable insights for the study. Participants who can express their experiences, thoughts, and feelings clearly will allow the researcher to delve deeper into the research objectives and gain a more comprehensive understanding of the phenomenon under investigation. Selecting individuals with the ability to articulate and reflect ensures that the data collected will be meaningful and contribute significantly to the research findings. It is essential for qualitative researchers to prioritize such participants who can best meet the objectives of the study by offering detailed and insightful perspectives.