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A nurse is caring for a patient who has undergone a total knee replacement. Which of the following interventions is most important to prevent post-operative complications?
- A. Encouraging early ambulation.
- B. Providing pain medication as needed.
- C. Monitoring for signs of infection.
- D. Administering antibiotics before surgery.
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. Early ambulation helps prevent complications such as deep vein thrombosis and pulmonary embolism by improving circulation and preventing blood clots. It also promotes joint mobility and muscle strength. Providing pain medication (B) is important but not as crucial as preventing complications. Monitoring for signs of infection (C) is essential but not the most important intervention. Administering antibiotics before surgery (D) does not directly prevent post-operative complications related to knee replacement.
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In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the:
- A. last glaucoma examination.
- B. frequency of breast self-examination.
- C. date of her last electrocardiogram.
- D. limitations related to her involvement in sports activities.
Correct Answer: D
Rationale: The correct answer is D because obtaining information on the limitations related to the girl's involvement in sports activities is crucial for assessing her overall physical health and well-being. This information helps in understanding any potential risks or issues that may arise from her participation in sports. Choices A, B, and C are incorrect as they are not relevant to a review of systems for a healthy 7-year-old girl. Glaucoma examination, breast self-examination frequency, and electrocardiogram date are not typically part of a routine review of systems for a child of her age and health status.
What is the correct interpretation of a drumlike sound heard during percussion of the abdomen?
- A. Constipation
- B. Air-filled areas
- C. The presence of a tumor
- D. The presence of dense organs
Correct Answer: B
Rationale: The correct interpretation of a drumlike sound heard during percussion of the abdomen is that it indicates air-filled areas within the abdomen. This sound, known as tympany, occurs when air is present in the gastrointestinal tract or hollow organs. Percussion produces a resonant, drum-like sound over these air-filled areas. This is a normal finding during a physical examination.
Incorrect Answers:
A: Constipation does not typically produce a drumlike sound during percussion. Constipation may cause a dull sound due to fecal matter retention.
C: The presence of a tumor would not cause a drumlike sound during percussion. Tumors are typically solid masses and would produce a dull sound during percussion.
D: Dense organs such as the liver or spleen would produce a dull sound, not a drumlike sound, during percussion due to their solid nature.
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 hypertension. The nurse should educate the patient to avoid which of the following?
- A. Increasing potassium intake.
- B. Consuming more fruits and vegetables.
- C. Limiting sodium intake.
- D. Increasing caffeine consumption.
Correct Answer: D
Rationale: The correct answer is D: Increasing caffeine consumption. Caffeine can potentially raise blood pressure in individuals with hypertension. The rationale is that caffeine is a stimulant that can lead to temporary spikes in blood pressure. This can be harmful for patients with a history of hypertension as it can exacerbate their condition.
A: Increasing potassium intake is generally recommended for individuals with hypertension as it can help lower blood pressure.
B: Consuming more fruits and vegetables is also beneficial for hypertension due to their high fiber and nutrient content.
C: Limiting sodium intake is crucial for managing hypertension as high sodium levels can lead to increased blood pressure.
In summary, increasing caffeine consumption is the correct answer to avoid for patients with hypertension, as it can potentially worsen their condition by raising blood pressure.
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.