Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: C

Rationale: The pharmacist is legally responsible in this situation because they are the healthcare professional authorized to dispense medications according to the physician's order. In this case, the physician ordered a dose higher than the maximum safe dose recommended based on the infant's current weight. While the nurse administers the medication, the pharmacist has the responsibility to ensure that the correct dose is dispensed and to alert the physician if there is a discrepancy in the order. If the pharmacist dispensed the incorrect dose without verifying with the physician, they would bear legal responsibility for any adverse effects resulting from the medication error.

Correct Answer: A

Rationale: The nurse should monitor serum potassium levels closely during ACE inhibitor therapy because ACE inhibitors can lead to an increase in serum potassium levels, known as hyperkalemia. ACE inhibitors block the conversion of angiotensin I to angiotensin II, which in turn decreases aldosterone secretion. Aldosterone normally acts in the kidneys to reabsorb sodium and water and excrete potassium. Therefore, when aldosterone secretion is decreased due to ACE inhibitor therapy, there can be an increase in potassium retention, potentially leading to hyperkalemia. Monitoring serum potassium levels is essential to prevent complications associated with hyperkalemia, such as cardiac arrhythmias.

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: A

Rationale: The patient is presenting with chest pain that worsens with exertion and improves with rest, which is characteristic of stable angina. Additionally, ST-segment depression on ECG is a common finding in patients with stable angina. Stable angina is typically caused by coronary artery disease, which leads to partial obstruction of the coronary arteries resulting in inadequate blood flow to the heart muscle during periods of increased demand (such as exertion). The chest pain is usually predictable and reproducible, occurring with similar intensity and duration during episodes of exertion. Rest or nitroglycerin can help relieve the symptoms by increasing coronary blood flow. It is important to differentiate stable angina from unstable angina and acute myocardial infarction, which have different management and prognostic implications.

Correct Answer: A

Rationale: Providing education on techniques to enhance milk production and supply should be prioritized to address the client's concerns about milk supply and meeting the baby's nutritional needs. By educating the client on proper breastfeeding techniques, frequent nursing sessions, skin-to-skin contact, and the importance of staying hydrated, the nurse can help promote successful breastfeeding and potentially increase milk production. Supplemental formula feedings are not the first line of intervention, as breastfeeding should be encouraged, especially for a preterm infant who may benefit significantly from breast milk. Encouraging the client to avoid breastfeeding until the infant reaches full term is not appropriate, as breastfeeding can still be beneficial for a preterm infant. Referring the client to a dietitian for specialized nutritional support may be beneficial, but addressing milk supply concerns through education should be prioritized initially to support breastfeeding success.