Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: C

Rationale: The most appropriate nursing action in this scenario is to notify the healthcare provider immediately. The client's presentation of calf pain, swelling, and warmth could be indicative of a deep vein thrombosis (DVT), which is a serious condition that requires prompt evaluation and intervention by the healthcare provider. DVT is a blood clot that forms in a deep vein, often in the leg, and if left untreated, it can lead to life-threatening complications such as pulmonary embolism. Therefore, timely communication with the healthcare provider is critical to ensure that the client receives the appropriate diagnostic testing and treatment to address the potential DVT. Applying warm compresses, encouraging ambulation, or administering NSAIDs would not be the first-line interventions for a suspected DVT and may even worsen the condition.

Correct Answer: C

Rationale: When caring for patients with hyperbilirubinemia, the nursing care plan should focus on informing the significant others, preventing injury, and preventing complications. The primary goal in managing hyperbilirubinemia is to prevent complications associated with high bilirubin levels, such as kernicterus. Therefore, maintaining physiological homeostasis with bilirubin levels increasing would not be appropriate and should not be the focus of the nursing care plan. It is crucial to monitor and manage bilirubin levels to prevent adverse outcomes rather than allowing them to increase.

Correct Answer: D

Rationale: In the scenario described, the patient is experiencing severe hypoxemia refractory to conventional oxygen therapy, indicating a need for advanced respiratory support. When a patient with ARDS fails to respond to conservative management, including mechanical ventilation strategies, prone positioning, and recruitment maneuvers, the next step may involve extracorporeal membrane oxygenation (ECMO). ECMO provides a way to bypass the lungs and oxygenate the blood directly, allowing for enhanced gas exchange and support for severely compromised respiratory function. Therefore, in this critical situation, prioritizing the recommendation for ECMO can offer the patient the best chance of improving oxygenation and survival.

Correct Answer: D

Rationale: Follicular thyroid carcinoma is a type of thyroid cancer that arises from the follicular cells of the thyroid gland. Patients with follicular thyroid carcinoma may present with a palpable thyroid nodule, which in this case is causing signs of hyperthyroidism due to the overproduction of thyroid hormones by the malignant cells. Fine-needle aspiration biopsy revealing follicular cells with nuclear features suggestive of malignancy further supports the diagnosis of follicular thyroid carcinoma in this scenario.

Correct Answer: B

Rationale: Phlebitis is the most common complication that patients may contract while on IV therapy. Phlebitis is the inflammation of the vein where the IV is inserted, which can cause redness, pain, and swelling along the vein. It can be caused by mechanical irritation, chemical irritation, or infection from the IV catheter. Prompt removal of the IV catheter and appropriate treatment are necessary to manage phlebitis and prevent further complications. While embolism, cardiac overload, and aneurysm are potential complications of IV therapy, phlebitis is more commonly seen in clinical practice.