Adult Health Nursing Test Bank

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.

Correct Answer: B

Rationale: The correct answer is B: Bright red and spurts with the heartbeat. This type of bleeding indicates arterial bleeding, which is oxygen-rich blood coming directly from the arteries. Arterial bleeding is bright red in color due to the high oxygen content and spurts with the heartbeat as it is under higher pressure. This rapid spurting is characteristic of arterial bleeding and requires immediate attention to control the bleeding source. Choices A, C, and D are incorrect because they describe characteristics of venous bleeding, not arterial bleeding. Venous bleeding is dark in color, flows slowly, and generally oozes as it is oxygen-depleted blood returning to the heart. Therefore, the correct answer is B based on the specific characteristics of arterial bleeding.

Correct Answer: C

Rationale: Step 1: Previous pregnancy experience is crucial for understanding the patient's obstetric history and potential risks. Step 2: It helps in identifying any complications or issues that may arise during the current pregnancy. Step 3: Laboratory results, prenatal check-up records, and diagnostic test results provide additional information but do not offer insights into the patient's past pregnancy experiences. Summary: Choice C is the most important as it directly relates to the patient's obstetric history, while the other options focus on current data that may not provide the same level of context.

Correct Answer: C

Rationale: The correct answer is C because encouraging the patient to ask questions and express concerns promotes patient empowerment and active participation in self-care. This approach fosters communication, understanding, and collaboration between the nurse and patient, leading to better medication adherence. Choice A is incorrect as it lacks patient involvement. Choice B is helpful but does not necessarily empower the patient. Choice D is directive and does not encourage active participation or empowerment.

Correct Answer: D

Rationale: The correct answer is D because an ethical dilemma arises when there is a conflict between two or more ethical principles, leading to a difficult decision-making situation for Nurse Mauve. This involves weighing the benefits and consequences of each ethical principle to determine the best course of action. Choice A is incorrect as time pressure does not define an ethical dilemma. Choice B is incorrect because ethical dilemmas involve conflicting choices, not unclear ones. Choice C is incorrect as the conflict in an ethical dilemma is not necessarily with a superior but can be internal or with other stakeholders.