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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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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.
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should monitor for signs of which of the following complications?
- A. Hypoglycemia.
- B. Respiratory failure.
- C. Hyperkalemia.
- D. Anemia.
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Patients with COPD are at risk for respiratory failure due to impaired gas exchange and respiratory muscle weakness. This can lead to hypoxia and hypercapnia. Monitoring for signs such as increased work of breathing, decreased oxygen saturation, and altered mental status is crucial.
Hypoglycemia (A) is not a common complication of COPD. Hyperkalemia (C) is less likely to occur in COPD unless the patient is on medications that can cause elevated potassium levels. Anemia (D) may be present in COPD due to chronic inflammation, but it is not a direct complication that requires monitoring for signs of respiratory failure.
A patient with diabetes is experiencing a hypoglycemic episode. Which of the following is the nurse's first priority in this situation?
- A. Administering insulin.
- B. Providing a source of fast-acting carbohydrate.
- C. Checking the patient's blood glucose level.
- D. Contacting the healthcare provider.
Correct Answer: B
Rationale: The correct answer is B: Providing a source of fast-acting carbohydrate. In a hypoglycemic episode, the priority is to raise the blood sugar quickly to prevent further complications. Fast-acting carbohydrates such as glucose tablets or orange juice can rapidly increase blood sugar levels. Administering insulin (choice A) can further lower blood sugar, checking blood glucose levels (choice C) may delay treatment, and contacting the healthcare provider (choice D) is not necessary in the immediate management of hypoglycemia.
A nurse is caring for a patient who is post-operative following a cesarean section. The nurse should prioritize which of the following interventions?
- A. Administering pain medication as prescribed.
- B. Encouraging the patient to breastfeed immediately.
- C. Monitoring for signs of hemorrhage.
- D. Encouraging ambulation to prevent deep vein thrombosis.
Correct Answer: C
Rationale: The correct answer is C: Monitoring for signs of hemorrhage. This is the priority intervention because post-cesarean section hemorrhage is a life-threatening complication that requires immediate attention. The nurse should monitor the patient's vital signs, uterine firmness, and amount of vaginal bleeding to detect any signs of hemorrhage and take prompt action if necessary.
Option A is incorrect because pain management is important but not the priority in this situation. Option B is also incorrect as breastfeeding can be encouraged after the patient's condition is stable. Option D is not the priority as preventing deep vein thrombosis is important but not as urgent as monitoring for hemorrhage.
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.