Adult Health Nursing Quizlet Final

Correct Answer: A

Rationale: The nurse's priority action when noticing a spill of bodily fluids on the floor while preparing the operating room for a surgical procedure is to clean up the spill using appropriate infection control measures. This is essential to prevent the spread of infections and ensure a safe surgical environment for both patients and healthcare providers. Cleaning up the spill promptly and properly reduces the risk of contamination and subsequent infections. Once the spill is cleaned up, the nurse can then proceed with documenting the spill, placing warning signs to alert others, and continuing with the preparation of the OR as planned. But the initial priority is to eliminate the immediate threat posed by the spill through proper cleaning and infection control measures.

Correct Answer: C

Rationale: Feedback is an essential indicator of effective communication because it allows the sender to understand how the message was received by the receiver. It provides an opportunity to clarify any misunderstandings, confirm understanding, and ensure that the communication has been successful. Without feedback, the sender cannot be sure if their message was accurately understood or if further explanation or clarification is needed. Effective communication involves a two-way exchange, and feedback plays a crucial role in ensuring that the message is effectively transmitted and received.

Correct Answer: A

Rationale: Providing education on strategies for initiating and maintaining milk supply should be prioritized to support successful breastfeeding in this situation. Preterm infants can benefit significantly from breast milk due to its unique composition that supports their growth and development. Educating the client on techniques such as pumping to establish and maintain milk supply, proper latching techniques, and understanding the benefits of breastfeeding for preterm infants can help alleviate her concerns and increase her confidence in breastfeeding her premature infant. Additionally, promoting skin-to-skin contact and frequent feedings can also help stimulate milk production and foster bonding between the mother and infant. Encouraging and supporting the client with evidence-based information will be crucial in promoting successful breastfeeding outcomes for the preterm infant.

Correct Answer: A

Rationale: Encouraging frequent position changes, including the hands-and-knees position, is the most appropriate nursing intervention in this scenario. This position is known to help rotate the baby from a persistent posterior position to an optimal anterior position for delivery. The hands-and-knees position can help take pressure off the mother's back, alleviate back pain, and facilitate the rotation of the baby's head to engage in the mother's pelvis, thus promoting labor progress. It is a non-invasive and effective way to promote fetal rotation without the need for immediate instrumental delivery or intravenous analgesics. Continuous fetal monitoring is important for assessing fetal well-being but would not directly address the issue of posterior fetal position and the associated prolonged labor.

Correct Answer: A

Rationale: Difficulty of speaking and chewing is an indicator of cranial nerve involvement. Cranial nerves are responsible for controlling various functions of the head and neck, including speech and mastication. Impairment of cranial nerve function can lead to difficulty in these activities. In the context of the question, with the patient in the stroke unit, cranial nerve involvement can occur due to the stroke affecting the brain regions responsible for cranial nerve function. Loss of pain sensation, spastic paralysis of the extremities, and forgetfulness with syncope are not specific indicators of cranial nerve involvement in this scenario.