Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: The medication given after a successful vaginal delivery that helps to hasten uterine contractility and control bleeding is typically an oxytocic agent, such as oxytocin. Oxytocin helps the uterus to contract effectively, which is important for preventing excessive bleeding after delivery. This medication is commonly used in the postpartum period to help the uterus return to its normal size and position. The supervisor reassured the newly hired nurse that everything will be fine because this medication will help promote uterine contractions and control bleeding, which are crucial steps in the postpartum management.

Correct Answer: C

Rationale: The priority nursing intervention to promote optimal wound healing in a client who had an episiotomy is providing perineal care using peri-bottles with warm water. Warm water helps to cleanse the area, reduce the risk of infection, and promote circulation, which aids in wound healing. Peri-bottles are especially gentle and effective in cleaning the perineal area without causing trauma to the incision site. Encouraging frequent perineal hygiene with soap and water may be too harsh on the incision site and could lead to irritation. Applying antibiotic ointment after each void is not necessary unless prescribed by the healthcare provider, as overuse of antibiotics can lead to resistance. Instructing the client on proper peri-pad application is important for comfort and cleanliness but is not as crucial as gentle perineal care using peri-bottles with warm water for promoting optimal wound healing.

Correct Answer: B

Rationale: The nurse's priority action when noticing an abnormal heart rhythm on the patient's cardiac monitor during surgery is to assess the patient's vital signs and symptoms. This is important because the nurse needs to gather more information about the patient's condition to determine the significance of the abnormal rhythm and the potential impact on the patient's health. By assessing the vital signs and symptoms, the nurse can obtain a more complete picture of the situation and make informed decisions about the next steps in caring for the patient. Once the assessment is done, appropriate actions such as administering medication or notifying the anesthesiologist can be taken based on the findings.

Correct Answer: B

Rationale: Long-term aspirin therapy, especially at higher doses, can increase the risk of gastrointestinal bleeding. Aspirin irreversibly inhibits cyclooxygenase enzyme, which is essential for the production of prostaglandins involved in mucosal protection of the gastrointestinal tract. Without these protective prostaglandins, the stomach lining becomes more susceptible to damage from gastric acid, leading to potential ulcer formation and bleeding. Patients with a history of coronary artery disease may be on aspirin for secondary prevention, and it is crucial to monitor for signs of bleeding such as black, tarry stools or abdominal pain. The benefits of aspirin in preventing cardiovascular events need to be weighed against the risk of adverse effects like gastrointestinal bleeding, especially in patients on long-term therapy.

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.