Foundations and Adult Health Nursing Study Guide Answers

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A postpartum client who had an episiotomy expresses concern about the appearance and healing of the incision site. What nursing intervention should be prioritized to promote optimal wound healing?

  • A. Encouraging frequent perineal hygiene with soap and water
  • B. Applying antibiotic ointment to the incision site after each void
  • C. Providing perineal care using peri-bottles with warm water
  • D. Instructing the client on proper peri-pad application to the incision
Correct Answer: C

Rationale: The priority nursing intervention to promote optimal wound healing in a client who had an episiotomy is providing perineal care using peri-bottles with warm water. Warm water helps to cleanse the area, reduce the risk of infection, and promote circulation, which aids in wound healing. Peri-bottles are especially gentle and effective in cleaning the perineal area without causing trauma to the incision site. Encouraging frequent perineal hygiene with soap and water may be too harsh on the incision site and could lead to irritation. Applying antibiotic ointment after each void is not necessary unless prescribed by the healthcare provider, as overuse of antibiotics can lead to resistance. Instructing the client on proper peri-pad application is important for comfort and cleanliness but is not as crucial as gentle perineal care using peri-bottles with warm water for promoting optimal wound healing.

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It is 10 o'clock of your watch. The client asks, "What time is it?" The nurse's appropriate response is:

  • A. "Are you bored?"
  • B. "It is 10 o'clock.".
  • C. "Why do you ask?"
  • D. "Guess, what time is it?"
Correct Answer: B

Rationale: The nurse's appropriate response is to provide the requested information clearly and directly. In this case, the client asked for the time, so the best response is to say "It is 10 o'clock" to answer their question promptly. Options A, C, and D do not address the client's question and may be perceived as dismissive or unhelpful.

A patient presents with fatigue, pallor, and exertional dyspnea. Laboratory tests reveal severe anemia, low serum iron, low transferrin saturation, and elevated total iron-binding capacity (TIBC). Which of the following conditions is most likely to cause these findings?

  • A. Iron deficiency anemia
  • B. Anemia of chronic disease
  • C. Sideroblastic anemia
  • D. Thalassemia
Correct Answer: A

Rationale: The clinical presentation of fatigue, pallor, exertional dyspnea along with the laboratory findings of severe anemia, low serum iron, low transferrin saturation, and elevated TIBC are consistent with iron deficiency anemia. In iron deficiency anemia, there is inadequate iron available for erythropoiesis leading to microcytic hypochromic anemia. The low serum iron and transferrin saturation, along with the elevated TIBC, indicate decreased iron stores and increased iron-binding capacity as the body tries to compensate for the deficiency by increasing absorption and recycling of iron. Anemia of chronic disease typically presents with mild to moderate anemia, normal to low TIBC, and low transferrin saturation due to iron sequestration in macrophages. Sideroblastic anemia usually has elevated serum iron, high saturation, and normal to low TIBC. Thalassemia presents with microcytic hyp

A nurse is preparing to perform a gastric lavage procedure for a patient with gastrointestinal bleeding. What action should the nurse prioritize to ensure procedural effectiveness?

  • A. Administering antacid medication to the patient before the procedure
  • B. Using lukewarm water for gastric lavage to avoid thermal injury
  • C. Limiting the lavage fluid volume to prevent fluid overload
  • D. Positioning the patient in a left lateral decubitus position during lavage
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.

Which of the following salivary glands is located superior and anterior to the ear and produces mainly serous saliva?

  • A. Parotid gland
  • B. Sublingual gland
  • C. Submandibular gland
  • D. Submaxillary gland
Correct Answer: A

Rationale: The parotid gland is the salivary gland that is located superior and anterior to the ear. It mainly produces serous saliva, which is a thin, watery fluid rich in enzymes. The other salivary glands mentioned are the sublingual gland, submandibular gland, and submaxillary gland, all of which have different locations and produce different types of saliva.

A patient presents with chest pain that worsens with exertion and improves with rest. An electrocardiogram (ECG) shows ST-segment depression. Which cardiovascular disorder is most likely responsible for these symptoms?

  • A. Stable angina
  • B. Unstable angina
  • C. Acute myocardial infarction
  • D. Prinzmetal's angina
Correct Answer: A

Rationale: The patient is presenting with chest pain that worsens with exertion and improves with rest, which is characteristic of stable angina. Additionally, ST-segment depression on ECG is a common finding in patients with stable angina. Stable angina is typically caused by coronary artery disease, which leads to partial obstruction of the coronary arteries resulting in inadequate blood flow to the heart muscle during periods of increased demand (such as exertion). The chest pain is usually predictable and reproducible, occurring with similar intensity and duration during episodes of exertion. Rest or nitroglycerin can help relieve the symptoms by increasing coronary blood flow. It is important to differentiate stable angina from unstable angina and acute myocardial infarction, which have different management and prognostic implications.

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