Foundations and Adult Health Nursing Test Bank

Correct Answer: C

Rationale: Nurse Ace submitting a report to the physician about committing an error in medication demonstrates accountability. Accountability in healthcare refers to the responsibility of individuals to answer for their actions, decisions, and behaviors in the professional setting. By taking ownership of the mistake and informing the physician, Nurse Ace is showing accountability for her actions, ensuring that patient safety remains a priority. Compliance with reporting errors is essential for quality improvement and patient safety in healthcare settings.

Correct Answer: A

Rationale: The incident report is the best source of factual information to investigate the fall further. Incident reports are official documents that provide a detailed account of what happened leading up to and during an incident. They include factual information such as the date, time, location, individuals involved, and details of the event. By reviewing the incident report, investigators can gather accurate information to determine the cause of the fall and any contributing factors. This document serves as an essential tool in conducting a thorough investigation into the fall and helps in identifying preventive measures to avoid similar incidents in the future.

Correct Answer: D

Rationale: The presentation of sudden-onset severe headache, vomiting, and altered mental status, along with the presence of a berry-shaped aneurysm on imaging, point towards a diagnosis of subarachnoid hemorrhage. The most common cause of a subarachnoid hemorrhage is the rupture of a saccular (berry) aneurysm, which commonly occurs at the junction of the anterior communicating artery and anterior cerebral artery. The sudden headache is often described as the "worst headache of my life" and is typically associated with nausea and vomiting. Altered mental status may be present due to the effects of increased intracranial pressure and possible associated brain injury. It is important to promptly diagnose and manage subarachnoid hemorrhage to prevent complications such as vasospasm, rebleeding, and ischemic deficits.

Correct Answer: D

Rationale: Before initiating any oxygen therapy, it is crucial for the nurse to first assess the patient's condition. This step allows the nurse to determine the patient's oxygen saturation levels, respiratory rate, lung sounds, and overall respiratory status. Understanding the patient's baseline condition helps in selecting the appropriate oxygen delivery method and flow rate that will best meet the patient's needs. Additionally, assessing the patient's condition allows the nurse to monitor the effectiveness of the oxygen therapy and make any necessary adjustments throughout the treatment process. Therefore, assessing the patient's condition is the necessary first step in providing safe and effective oxygen therapy.

Correct Answer: A

Rationale: Assisting the mother into a hands-and-knees position should be prioritized to facilitate fetal rotation and optimize labor progress in the case of persistent occiput posterior fetal position. This position helps in promoting fetal rotation to a more favorable position for delivery by allowing the baby's head to move into the anterior position. It can help alleviate back pain and may help reduce the duration of labor. This simple maneuver can sometimes correct the malposition without the need for interventions like instrumental delivery. It is a non-invasive and effective technique that can be easily implemented by healthcare providers to support the progression of labor.