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A nurse is caring for a patient who has undergone a colonoscopy. The nurse should prioritize monitoring for which of the following complications?
- A. Hypotension.
- B. Bleeding or perforation.
- C. Constipation.
- D. Pain at the insertion site.
Correct Answer: B
Rationale: The correct answer is B: Bleeding or perforation. After a colonoscopy, the patient is at risk for bleeding or perforation which are serious complications requiring immediate attention. Monitoring for signs such as abdominal pain, rectal bleeding, or signs of peritonitis is crucial. Choice A is not a priority unless the patient shows signs of shock. Choice C is a common post-procedure issue but not a priority complication. Choice D, pain at the insertion site, is expected and can be managed with analgesics.
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A nurse is teaching a patient with diabetes about managing their condition. Which of the following statements by the patient indicates proper understanding?
- A. I will monitor my blood glucose regularly.
- B. I can stop taking my insulin when my blood glucose is normal.
- C. I should only use my insulin when I feel symptoms of high blood sugar.
- D. I will eat sugary foods if I feel tired or weak.
Correct Answer: A
Rationale: The correct answer is A: "I will monitor my blood glucose regularly." This statement shows proper understanding as monitoring blood glucose levels is essential for managing diabetes effectively. Regular monitoring helps the patient track their blood sugar levels and make informed decisions about medication, diet, and lifestyle.
Incorrect choices:
B: Stopping insulin when blood glucose is normal can lead to dangerous complications.
C: Using insulin only when symptoms of high blood sugar are present is not a safe or effective approach.
D: Eating sugary foods when feeling tired or weak can cause blood sugar spikes and worsen diabetes control.
In summary, choice A is correct because it reflects the importance of consistent blood glucose monitoring in diabetes management, while the other choices suggest potentially harmful misconceptions.
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following signs of exacerbation?
- A. Increased sputum production and shortness of breath.
- B. Improved oxygen saturation.
- C. Increased energy levels.
- D. Decreased respiratory rate.
Correct Answer: A
Rationale: The correct answer is A because increased sputum production and shortness of breath are classic signs of exacerbation in COPD. This indicates worsening airflow limitation and potential respiratory distress. Monitoring these signs helps in early intervention and preventing further complications.
B: Improved oxygen saturation is not a sign of exacerbation in COPD. It would actually suggest improvement in the patient's condition.
C: Increased energy levels are not typical signs of exacerbation in COPD. Patients usually experience fatigue and weakness during exacerbations.
D: Decreased respiratory rate is not indicative of exacerbation in COPD. It could be a sign of respiratory depression or sedation, but not exacerbation.
A patient with a history of diabetes presents with a wound on the foot that is not healing. The nurse would be concerned about the possibility of:
- A. Peripheral vascular disease.
- B. Deep vein thrombosis.
- C. Cellulitis.
- D. Skin cancer.
Correct Answer: A
Rationale: The correct answer is A: Peripheral vascular disease. In a patient with diabetes, poor blood circulation due to damaged blood vessels can lead to delayed wound healing. Peripheral vascular disease is a common complication of diabetes that can result in inadequate blood flow to the extremities, impairing wound healing. Deep vein thrombosis (B) is a blood clot issue, not directly related to poor wound healing. Cellulitis (C) is a bacterial skin infection that can occur in anyone, not just diabetics. Skin cancer (D) is a condition unrelated to the wound healing process in this context.
A nurse is caring for a patient with a history of stroke. The nurse should monitor the patient for signs of:
- A. Pulmonary embolism.
- B. Atrial fibrillation.
- C. Chronic kidney disease.
- D. Sepsis.
Correct Answer: B
Rationale: The correct answer is B: Atrial fibrillation. Patients with a history of stroke are at an increased risk of atrial fibrillation, a common cause of ischemic stroke. Monitoring for signs of atrial fibrillation such as irregular heartbeat, palpitations, dizziness, and chest discomfort is crucial for early detection and prevention of recurrent strokes. Pulmonary embolism (A), chronic kidney disease (C), and sepsis (D) are not directly associated with a history of stroke and would not be the primary focus of monitoring in this case.
When a nurse is assessing a patient's pain level, which of the following questions would be most appropriate?
- A. "How would you rate your pain on a scale from 0 to 10?"
- B. "When did your pain start?"
- C. "What causes your pain?"
- D. "Do you need any medication for the pain?"
Correct Answer: A
Rationale: Step 1: Asking the patient to rate pain on a scale of 0 to 10 is a standard pain assessment tool, allowing for quantification and tracking of pain intensity.
Step 2: This question helps in understanding the severity of pain objectively.
Step 3: It provides a baseline for further pain management interventions.
Step 4: Other choices are incorrect as they do not directly address assessing pain intensity or severity.
Summary: Option A is the most appropriate as it focuses on quantifying pain, which is crucial for effective pain management. Choices B, C, and D are not as relevant for assessing pain intensity.