Foundations and Adult Health Nursing Test Bank

Correct Answer: A

Rationale: Pre-eclampsia is a serious condition that can occur during pregnancy, usually after 20 weeks gestation. It is important to screen for pre-eclampsia early in the pregnancy to monitor and manage the condition effectively. Screening for pre-eclampsia typically begins in the first trimester of pregnancy to identify any risk factors and provide appropriate care for the patient. Therefore, Nurse Vera informing the patient to get screened for pre-eclampsia in the first term of pregnancy is the most appropriate time to start monitoring for this condition.

Correct Answer: C

Rationale: It is essential for nurses to record vital signs and notes on a patient as soon as they obtain them. This allows for accurate and timely documentation of crucial information related to the patient's health status. By recording the information promptly, nurses can ensure that they do not forget important details and can provide effective care based on accurate data. Waiting for lunch break or after completing other tasks can lead to delays in documentation, which may compromise patient care and safety. Therefore, the ideal and proper time for recording vital signs and notes is immediately after obtaining them.

Correct Answer: D

Rationale: Since Nadine is just four years old, determining her favorite toys is not a critical aspect for Nurse Alma to consider in terms of routines and rituals. While knowing Nadine's favorite toys may help provide comfort or distraction, it is not as essential as ensuring proper feeding, sleep patterns, and toilet training for a young child's well-being and development. The focus should primarily be on aspects that directly impact her physical health, growth, and daily routines at this age.

Correct Answer: A

Rationale: In delegation, facilitating the professional growth and development of a staff is necessary because it allows team members to gain new skills and experience, leading to overall improved productivity and job satisfaction. This empowers staff and helps them feel more engaged in their work, ultimately benefiting the entire unit. Effective delegation should aim to support individuals in their roles, encourage learning, and build competence, rather than modifying standards of care or only delegating tasks without considering individual growth. Starting delegation from top management to staff-nurse level may not always be practical or efficient, as delegation should be based on competencies and responsibilities. Accountability is indeed a crucial aspect of delegation, as individuals should be held responsible for the tasks they are delegated. However, without providing opportunities for professional growth and development, delegation may not be as effective in achieving organizational goals.

Correct Answer: C

Rationale: If the nurse notices that the patient's arms are not adequately padded while positioning for surgery, the nurse should immediately take action to prevent pressure injuries. Applying soft padding to the patient's arms will help distribute the pressure more evenly, reducing the risk of skin breakdown and potential harm to the patient during the surgical procedure. It is essential to prioritize the patient's safety and comfort in such situations. Simply proceeding with the positioning as planned could lead to complications, so addressing the inadequate padding promptly is the appropriate course of action.