Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: C

Rationale: If Jose is complaining of dyspnea despite continuous oxygen therapy, the nurse's initial intervention should be to assess the patency of the tubing delivering the oxygen. A blockage in the tubing could restrict the flow of oxygen to the patient, leading to inadequate oxygen delivery and worsening dyspnea. By ensuring the tubing is clear and functioning properly, the nurse can address a potential issue with oxygen delivery before considering other interventions like giving PRN medication or involving the physician. Re-assessing the patient would also be important after ensuring the tubing's patency to evaluate the effectiveness of the intervention.

Correct Answer: A

Rationale: Prolonged rupture of membranes (>24 hours) increases the risk of intrauterine infection for both the mother and the fetus. When the amniotic sac has been ruptured for an extended period, there is a higher likelihood of bacteria entering the uterus, leading to chorioamnionitis (inflammation of the fetal membranes due to infection). Intrauterine infection can be dangerous for both the mother and fetus, potentially causing sepsis, preterm labor, and other complications. Therefore, it is crucial for the nurse to assess for signs and symptoms of infection in both the mother and fetus when managing a woman in active labor with prolonged rupture of membranes.

Correct Answer: A

Rationale: Patients with COPD are at increased risk for developing ventilator-induced lung injury (VILI) due to their underlying lung pathology. Using a low tidal volume strategy (6-8 ml/kg predicted body weight) has been shown to reduce the risk of VILI in these patients. Additionally, applying high positive end-expiratory pressure (PEEP) helps to recruit collapsed alveoli, improve oxygenation, and decrease the risk of barotrauma by keeping the alveoli open throughout the respiratory cycle. Therefore, the most appropriate ventilator settings to minimize the risk of VILI in a COPD patient with acute exacerbation and respiratory failure requiring mechanical ventilation would be low tidal volume and high PEEP.

Correct Answer: B

Rationale: Marlene opening up to the nurse about their financial difficulty indicates that she feels comfortable enough to share personal information with the nurse. This signals the establishment of a trusting relationship between Marlene and the nurse, as Marlene feels safe and supported enough to disclose sensitive information. Building trust is a crucial aspect of any professional relationship, especially in healthcare settings, as it fosters open communication, encourages honesty, and ultimately leads to better outcomes for the patient. It is an essential foundation for providing effective care and support to individuals in need.

Correct Answer: B

Rationale: Maternal anxiety can contribute to a prolonged latent phase during labor. Stress and anxiety can trigger the release of stress hormones such as adrenaline, which can interfere with the production of oxytocin, the hormone responsible for initiating contractions. This can result in irregular and ineffective contractions, leading to a prolonged latent phase. It is important for the nurse to assess the woman's anxiety levels and provide reassurance and support to help facilitate the progression of labor.