Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: Phlebitis is the most common complication that patients may contract while on IV therapy. Phlebitis is the inflammation of the vein where the IV is inserted, which can cause redness, pain, and swelling along the vein. It can be caused by mechanical irritation, chemical irritation, or infection from the IV catheter. Prompt removal of the IV catheter and appropriate treatment are necessary to manage phlebitis and prevent further complications. While embolism, cardiac overload, and aneurysm are potential complications of IV therapy, phlebitis is more commonly seen in clinical practice.

Correct Answer: B

Rationale: Running water in the sink or shower is a priority nursing measure to stimulate the sensation of voiding in postpartum mothers experiencing difficulty due to edema and trauma of the perineum. The sound and sight of running water can help relax the pelvic floor muscles and trigger the urge to void. This technique is commonly used in clinical practice to facilitate voiding and prevent urinary retention in postpartum women.

Correct Answer: B

Rationale: Streptococcus pneumoniae is the most common causative organism of bacterial pneumonia in adults. It is responsible for the majority of community-acquired pneumonia cases. Streptococcus pneumoniae is a gram-positive bacteria and is known to cause typical pneumonia characterized by sudden onset of high fever, productive cough with blood-tinged or rust-colored sputum, chest pain, and consolidation on chest imaging. Other organisms like Legionella pneumophila (choice A), Mycoplasma pneumoniae (choice C), and Haemophilus influenzae (choice D) can also cause pneumonia, but Streptococcus pneumoniae is the most likely culprit based on the patient's test results.

Correct Answer: C

Rationale: The correct action for the nurse to take when observing signs of distress and discomfort in a patient during assessment is to offer emotional support and actively listen to the patient's concerns. Ignoring the patient's distress may lead to worsening of the patient's condition and can be detrimental to the patient's well-being. Documenting the findings and informing the healthcare provider later is important but should not be the immediate response when a patient is in distress. Administering pain medication without further assessment is also not appropriate as the nurse needs to understand the underlying cause of the distress before providing appropriate interventions. Offering emotional support and actively listening to the patient's concerns can help the nurse understand the patient's needs, provide comfort, and potentially address the root cause of the distress.

Correct Answer: B

Rationale: The nurse's appropriate response is to provide the requested information clearly and directly. In this case, the client asked for the time, so the best response is to say "It is 10 o'clock" to answer their question promptly. Options A, C, and D do not address the client's question and may be perceived as dismissive or unhelpful.