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A nurse is caring for a patient who is post-operative following a hip replacement. The nurse should monitor for which of the following complications?
- A. Pneumonia.
- B. Deep vein thrombosis (DVT).
- C. Wound infection.
- D. Hypoglycemia.
Correct Answer: B
Rationale: The correct answer is B: Deep vein thrombosis (DVT). Post-operative hip replacement patients are at high risk for DVT due to immobility and surgical trauma. The nurse should monitor for signs such as swelling, redness, and pain in the affected leg. DVT can lead to serious complications like pulmonary embolism if not detected early. Choices A, C, and D are incorrect because while pneumonia, wound infection, and hypoglycemia are also potential post-operative complications, they are not as directly associated with hip replacement surgery as DVT.
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Which of the following is the appropriate health promotion question to ask during a review of symptoms?
- A. "Do you use sunscreen while outside?"
- B. "I need to see if your skin is warm and dry."
- C. "Have you experienced any dizziness or headaches?"
- D. "When you cough, what colour is the sputum you bring up?"
Correct Answer: A
Rationale: The correct answer is A: "Do you use sunscreen while outside?" because it directly relates to health promotion by addressing preventive measures. Sunscreen helps prevent skin cancer and other skin conditions. Choice B is incorrect as it focuses on assessing skin condition rather than promoting health. Choice C is incorrect as it relates to symptoms rather than prevention. Choice D is incorrect as it is related to assessing a specific symptom rather than promoting overall health.
A patient is admitted to the hospital with suspected pneumoniWhat is the first step the nurse should take in the nursing process?
- A. Diagnosis
- B. Assessment
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: The correct answer is B: Assessment. The first step in the nursing process is to assess the patient's condition to gather data and information. In this case, assessing the patient's symptoms, vital signs, and history will help the nurse identify signs of pneumonia and determine the appropriate interventions. Diagnosis (A) comes after assessment, as it involves analyzing the data collected. Implementation (C) and Evaluation (D) are subsequent steps in the nursing process after assessment and diagnosis have been completed. Assessment is crucial for developing an effective care plan and ensuring the best possible outcomes for the patient.
The nurse is unable to identify any changes in sound when percussing over the abdomen of an obese patient. What should the nurse do next?
- A. Ask the patient to take deep breaths to relax the abdominal musculature.
- B. Consider this a normal finding, and proceed with the abdominal assessment.
- C. Use less force to percuss over the abdomen.
- D. Use more force to percuss over the abdomen.
Correct Answer: C
Rationale: The correct answer is C: Use less force to percuss over the abdomen. When percussing an obese patient's abdomen, more force may not be effective due to the increased tissue thickness. Using less force allows for better transmission of sound waves through the tissues, improving the nurse's ability to assess for changes in sound. Asking the patient to take deep breaths (choice A) may help relax the abdominal muscles but won't address the issue of increased tissue thickness. Considering it a normal finding (choice B) without attempting to improve assessment techniques could lead to missed abnormalities. Using more force (choice D) can be uncomfortable for the patient and may still not produce clear sounds due to the tissue barrier.
Which of the following positions is most appropriate for performing an abdominal examination on an obese patient?
- A. Head elevated to 45 degrees
- B. Have the patient lie flat
- C. Place the patient in the supine position
- D. Position the patient on their side
Correct Answer: C
Rationale: The correct answer is C: Place the patient in the supine position. This position allows optimal access to the abdomen for examination due to gravitational forces aiding in organ palpation. Having the patient lie flat (choice B) may not provide adequate access. Positioning the patient on their side (choice D) may limit visibility and palpation. Elevating the head to 45 degrees (choice A) is unnecessary for an abdominal examination on an obese patient.
Which technique should be used to assess a murmur in a patient's heart?
- A. The bell of the stethoscope
- B. The diaphragm of the stethoscope
- C. Palpation with the palm of the hand
- D. Ask another nurse to double-check the finding.
Correct Answer: B
Rationale: The correct answer is B: The diaphragm of the stethoscope. The diaphragm is used to assess heart murmurs as it allows for higher-frequency sounds to be heard more clearly. When assessing heart murmurs, using the diaphragm helps to differentiate between systolic and diastolic murmurs, as well as to identify specific characteristics such as intensity and location.
A: The bell of the stethoscope is used for low-frequency sounds and would not be ideal for assessing heart murmurs.
C: Palpation with the palm of the hand is used to assess pulses and vibrations, not heart murmurs.
D: Asking another nurse to double-check the finding is important for validation but does not directly relate to the technique used to assess a heart murmur.