Adult Health Med Surg Nursing Test Banks

Correct Answer: D

Rationale: Record keeping involves several key steps such as structuring, securing, and storing information. However, easy disposal is not a step in record keeping. In fact, it is important to carefully consider the disposal of records in a secure and responsible manner to protect sensitive information and comply with relevant regulations. Proper disposal methods should be followed to ensure that records are not accessible to unauthorized individuals and that any sensitive information is properly destroyed to prevent misuse or breaches of privacy. Therefore, easy disposal is not a recommended practice in effective record keeping.

Correct Answer: A

Rationale: The first responsibility of a nurse when a patient falls is to assess the patient's injury. Assessing the patient's injury immediately allows the nurse to determine the severity of the fall and provide appropriate care and interventions. It is important to assess for any signs of injury, such as pain, swelling, bruising, or altered mobility, and to address any immediate medical needs. Once the patient's injury has been assessed, the nurse can then proceed to report the incident to the head nurse, write an incident report, and notify the physician if necessary.

Correct Answer: A

Rationale: Rehabilitation prior to discharge is best described as a period of ups and downs, physically and emotionally because it involves the recovery process after an illness, injury, or medical procedure. It is a challenging time where the patient may experience setbacks and improvements on their journey back to health. There can be physical challenges such as regaining strength and mobility, as well as emotional challenges like coping with the changes in their condition. Therefore, the rehabilitation process is often not smooth and can be a rollercoaster of progress and setbacks, both physically and emotionally.

Correct Answer: D

Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.

Correct Answer: C

Rationale: Using an expired skin preparation solution can compromise the safety and effectiveness of the surgical site cleansing. Expired solutions may have reduced efficacy or could cause adverse reactions due to chemical breakdown over time. Therefore, it is essential for the nurse to discard the expired solution and obtain a new one to ensure proper sanitation and reduce the risk of complications during the surgical procedure. It is important to adhere to proper protocols and guidelines in healthcare settings to maintain patient safety and optimal outcomes.