Adult Health Nursing Answer Key

Correct Answer: A

Rationale: The purpose of asking Nurse Rosie to submit an Incident Report (IR) is most likely to note patterns of incidences in the same unit. Incident reports are essential tools in healthcare settings to track and analyze unexpected events, errors, or situations that may impact patient care and safety. By collecting and reviewing incident reports, the head nurse can identify trends, patterns, or commonalities in the occurrences within the unit. This information allows for targeted interventions, improvements in practices, and enhanced patient safety. Therefore, asking Nurse Rosie to submit an IR would serve the purpose of noting patterns of incidences in the same unit for proactive and quality care delivery.

Correct Answer: B

Rationale: Sexual dysfunctions like impotence, erectile dysfunction, and lack of libido are common complications following prostatic surgery. Among the options provided, transurethral resection of the prostate (TURP) is associated with a higher risk of these sexual dysfunctions. This is because during TURP, the surgical procedure may damage nerves and blood vessels that are crucial for sexual function, leading to impotence, erectile dysfunction, and decreased libido postoperatively.

Correct Answer: C

Rationale: In situations where a patient's family member is expressing anxiety about their loved one's condition, it is important for the nurse to provide clear and accurate information about the patient's status. By explaining the nature of the injury and reassuring the wife that her husband's condition is stable, the nurse can help alleviate her anxiety and address her concerns in a meaningful way. This intervention focuses on open communication and providing emotional support, which are crucial in helping the family member cope with the situation. It is essential to establish trust and create a supportive environment for the family member during this stressful time.

Correct Answer: A

Rationale: The correct nursing intervention to prioritize in this situation is providing education on techniques to improve latch and milk transfer. Cesarean section deliveries can sometimes pose challenges for breastfeeding initiation, but with proper education and support, many women can successfully breastfeed following a C-section. By teaching the client techniques to improve latch and milk transfer, the nurse can help address the client's concerns about breastfeeding difficulties and worries about insufficient milk supply. This proactive approach empowers the client to overcome breastfeeding challenges and increase their confidence in their ability to breastfeed successfully. Referring the client to a lactation consultant for specialized support may also be beneficial, but providing initial education on latch and milk transfer is crucial in this early postpartum period. Recommending formula feedings or discouraging breastfeeding may not be appropriate interventions, as they can affect the establishment of breastfeeding and undermine the client's breastfeeding goals.

Correct Answer: B

Rationale: Meconium-stained amniotic fluid indicates that the fetus may have passed stool in utero, which can lead to potential respiratory problems once born due to meconium aspiration. The priority action for the nurse in this situation is to prepare for immediate delivery to expedite the removal of the fetus from the contaminated environment and provide necessary interventions such as suctioning of the airway to prevent aspiration of meconium. Prompt delivery is crucial to minimize the risk of complications related to meconium aspiration syndrome. Administering oxygen, inserting a urinary catheter, and notifying the neonatal resuscitation team can be important subsequent actions, but the immediate focus should be on delivering the baby.