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: The nurse should prioritize positioning the patient in a left lateral decubitus position during gastric lavage to ensure procedural effectiveness. This position helps to promote optimal drainage of fluid and gastric contents. Placing the patient in a left lateral position allows gravity to assist in the passage of fluid and prevents the risk of aspiration. It also helps to minimize the risk of complications such as reflux of lavage fluid into the respiratory tract. Proper positioning is essential in enhancing the success of the gastric lavage procedure and promoting patient safety.

Correct Answer: B

Rationale: Records are IMPORTANT in health care as they serve as evidence of the health care services that have been provided to a patient. These records contain vital information such as the patient's medical history, diagnoses, treatments, medications, and test results. Keeping accurate and detailed records is crucial for monitoring a patient's progress, ensuring appropriate care is being provided, and serving as a reference point for healthcare providers involved in the patient's treatment. Additionally, health care records are essential for legal and insurance purposes, quality assessment, research, and continuity of care.

Correct Answer: A

Rationale: As a QA nurse, Nurse Jen can adopt concurrent evaluation methods to assess patient outcomes in the unit. The most appropriate options for concurrent evaluation are Face to face interview with nursing staff (III) and Nursing audit from the patient's chart (IV).

Correct Answer: B

Rationale: Running water in the sink or shower is a priority nursing measure to stimulate the sensation of voiding in postpartum mothers experiencing difficulty due to edema and trauma of the perineum. The sound and sight of running water can help relax the pelvic floor muscles and trigger the urge to void. This technique is commonly used in clinical practice to facilitate voiding and prevent urinary retention in postpartum women.