Adult Health Nursing Quizlet Final

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The patient seems indecisive whether to breastfeed her baby or not. Which is the desired nursing action of Nurse Vera to help the pregnant patient make a decision on breastfeeding?

  • A. Give pamphlets and books to read.
  • B. Provide ample time for the patient to decide.
  • C. Refer the patient to the nutrionist.
  • D. Assist to identify breastfeeding goal and plan.
Correct Answer: D

Rationale: The desired nursing action to help the pregnant patient make a decision on breastfeeding is to assist in identifying a breastfeeding goal and plan. When patients are indecisive about breastfeeding, it is essential for the nurse to support them in setting specific goals and creating a plan that aligns with their values and circumstances. This approach can help the patient feel empowered and confident in their decision-making process. Providing pamphlets and books (choice A) may be helpful, but personalized assistance in identifying a breastfeeding goal and plan is more likely to address the patient's individual needs and concerns. Providing ample time for the patient to decide (choice B) is important, but guidance and support in setting a clear goal can facilitate the decision-making process. Referring the patient to a nutritionist (choice C) may be beneficial for dietary concerns but may not directly address the decision-making process regarding breastfeeding.

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The patient began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. The patient complains of difficulty of breathing, itching and a tight sensation in the chest. Which is the IMMEDIATE action of the nurse?

  • A. Recheck the unit of blood for compatibility.
  • B. Call the physician.
  • C. Check the patient 's temperature.
  • D. Stop the infusion.
Correct Answer: D

Rationale: The symptoms described by the patient indicate a potential transfusion reaction, such as a hemolytic reaction or allergic reaction. The immediate action the nurse should take in such a situation is to stop the infusion of the packed red blood cells. This will help prevent further complications and ensure the safety of the patient. After stopping the infusion, the nurse should assess the patient's condition, monitor vital signs, and inform the healthcare team, including the physician, regarding the situation. Once the patient is stable, further investigations can be conducted to determine the cause of the reaction.

A patient with a history of heart failure presents with dependent edema in the lower extremities. Which nursing action is most appropriate for managing the patient's edema?

  • A. Applying compression stockings
  • B. Elevating the legs above heart level
  • C. Administering diuretics as prescribed
  • D. Encouraging increased fluid intake
Correct Answer: C

Rationale: The most appropriate nursing action for managing a patient with dependent edema in the lower extremities is to administer diuretics as prescribed. Diuretics help the body remove excess fluid, reducing swelling and edema in the extremities. It is important to follow the healthcare provider's orders for administering diuretics to ensure the patient's fluid balance is managed effectively. While elevating the legs above heart level and applying compression stockings may provide temporary relief, addressing the underlying cause of fluid retention with diuretics is essential for long-term management of the edema in a patient with heart failure. Encouraging increased fluid intake would not be appropriate in this case, as the focus should be on reducing fluid overload rather than increasing fluid intake.

A nurse is caring for a patient with limited mobility and is planning interventions to prevent pressure injuries. What action by the nurse demonstrates evidence-based practice in pressure injury prevention?

  • A. Applying moisturizing lotion to the patient's skin daily
  • B. Turning and repositioning the patient every 2 hours
  • C. Placing the patient on an alternating pressure mattress
  • D. Massaging the bony prominences to improve circulation
Correct Answer: C

Rationale: Placing the patient on an alternating pressure mattress demonstrates evidence-based practice in pressure injury prevention. Alternating pressure mattresses are designed to change pressure points by alternating pressure across different parts of the body, reducing the risk of pressure injuries. Regularly turning and repositioning the patient (Choice B) is also important in preventing pressure injuries, but an alternating pressure mattress provides additional support and prevention measures. Applying moisturizing lotion (Choice A) and massaging bony prominences (Choice D) may be beneficial for skin care, but they are not proven strategies for pressure injury prevention.

Patient Haydee comes to the perinatal unit of Hospital DEE. Nurse Arcee does through SCREENING assessment. Which is the Least screening assessment to be used by the nurse/

  • A. Physical examination
  • B. Radiologic procedures
  • C. Interview
  • D. Laboratory review
Correct Answer: B

Rationale: Radiologic procedures are typically not used as the least screening assessment by nurses in a perinatal unit. The nurse's initial screening assessments usually focus on gathering information through techniques such as physical examination, interviews, and reviewing laboratory results. Radiologic procedures, such as X-rays or CT scans, are usually ordered by physicians once a more specific diagnostic need has been identified, based on the initial screening assessments performed by the nurse. Therefore, in this scenario, the least screening assessment to be used by the nurse would be radiologic procedures.

which of the following is an EXTRANEOUS variable of the study?

  • A. Age of patients .
  • B. Length of stay 4-5 days.
  • C. Absence of complications.
  • D. Date of admission January-March.
Correct Answer: B

Rationale: The extraneous variable in a study is a variable that is not the main focus of the study but could potentially impact the results. In this case, the length of stay is an extraneous variable because it is not directly related to the research question or objective of the study. The study is likely focused on factors such as patient age, complications, or date of admission, making the length of stay an irrelevant variable in this context.

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