Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: C

Rationale: The best thing for Nurse Kayla to do for the patient is to encourage her to ambulate and to void. In this scenario, the fundus being firm, above the umbilicus, and deviated to the right indicates uterine atony with a full bladder. This finding is suggestive of a distended bladder pushing the uterus upwards and to the right. Encouraging the patient to ambulate helps promote uterine contractions, which can aid in the firming up of the uterus. Additionally, emptying the bladder will help the uterus to contract and return to its midline position. This intervention is non-invasive and promotes normal postpartum recovery without the need for medication or excessive manipulation.

Correct Answer: D

Rationale: When a patient is admitted to the OB ward with complaints of dizziness and body weakness, this information pertains to what the patient is feeling or experiencing, which is subjective data. Subjective data is based on the patient's symptoms, feelings, and experiences as reported by the patient themselves. In this case, dizziness and body weakness are subjective symptoms described by the patient, and they cannot be objectively measured or quantified. It is essential for healthcare providers to consider subjective data along with objective data (measurable and observable signs) when assessing and diagnosing a patient's condition.

Correct Answer: D

Rationale: The nurse should prioritize positioning the patient in a left lateral decubitus position during gastric lavage to ensure procedural effectiveness. This position helps to promote optimal drainage of fluid and gastric contents. Placing the patient in a left lateral position allows gravity to assist in the passage of fluid and prevents the risk of aspiration. It also helps to minimize the risk of complications such as reflux of lavage fluid into the respiratory tract. Proper positioning is essential in enhancing the success of the gastric lavage procedure and promoting patient safety.

Correct Answer: A

Rationale: The client is exhibiting signs and symptoms of respiratory alkalosis. When a person is experiencing respiratory alkalosis, there is an excessive loss of carbon dioxide (CO2) from the body, leading to elevated blood pH. The marked increase in the rate and depth of respirations as well as symptoms of anxiety, restlessness, and irritability are characteristic of respiratory alkalosis. This condition can be caused by hyperventilation, anxiety, or fever, which result in excessive elimination of CO2 from the body, leading to an imbalance in the acid-base status. Treatment for respiratory alkalosis involves addressing the underlying cause, such as providing reassurance to decrease anxiety or managing the breathing pattern to normalize CO2 levels.

Correct Answer: B

Rationale: Avascular necrosis of the femoral head, also known as osteonecrosis, is a common complication associated with hip fractures in elderly patients. It occurs when there is a loss of blood supply to the femoral head following the fracture, leading to bone tissue death. This can result in pain, limitation of motion, and potentially the collapse of the femoral head, causing further complications. Timely diagnosis and appropriate management are crucial in order to prevent further degeneration of the hip joint. Other complications such as compartment syndrome, dislocation of the hip prosthesis, and Volkmann's contracture are not typically associated with hip fractures in elderly patients.