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A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following in the immediate post-operative period?
- A. Administering pain medication.
- B. Encouraging deep breathing and coughing exercises.
- C. Monitoring for signs of infection.
- D. Providing the patient with solid food.
Correct Answer: B
Rationale: The correct answer is B: Encouraging deep breathing and coughing exercises. This is prioritized in the immediate post-operative period to prevent respiratory complications like atelectasis and pneumonia. Deep breathing helps to expand the lungs and coughing helps clear secretions. Administering pain medication (A) is important but not the top priority. Monitoring for signs of infection (C) is crucial but usually done after ensuring respiratory stability. Providing solid food (D) is contraindicated initially to prevent post-operative complications like ileus.
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What is the most appropriate action when a client with suspected meningitis presents with a positive Brudzinski sign?
- A. Place the client on their back and administer pain medication
- B. Place the client on their side and administer antibiotics
- C. Administer IV fluids and antibiotics
- D. Perform a lumbar puncture
Correct Answer: D
Rationale: The correct answer is D, perform a lumbar puncture. A positive Brudzinski sign indicates meningeal irritation, a hallmark of meningitis. A lumbar puncture is the gold standard for diagnosing meningitis by analyzing cerebrospinal fluid. Placing the client on their back without proper diagnosis or treatment delays could lead to serious complications. Option B is incorrect as antibiotics should be given after confirming the diagnosis. Option C is partially correct but does not address the need for a definitive diagnostic test. Option A is incorrect as pain medication alone does not address the underlying cause of meningitis.
Which is included only in a comprehensive assessment?
- A. Circulatory assessment
- B. Assessment of the airway
- C. Complete health history
- D. Disability assessment
Correct Answer: C
Rationale: The correct answer is C: Complete health history. In a comprehensive assessment, obtaining a complete health history is essential to gather information about the patient's past and present health conditions, including medical history, family history, social history, and current symptoms. This information helps the healthcare provider understand the patient's overall health status, identify risk factors, and develop an appropriate treatment plan. Assessing the circulatory system (A) and airway (B) are important components of a physical assessment, but they alone do not constitute a comprehensive assessment. Disability assessment (D) focuses on the functional limitations caused by a disability and is not always included in a comprehensive health assessment.
What should the nurse assess first in a client with severe abdominal pain?
- A. Assess vital signs
- B. Administer oxygen
- C. Perform an ECG
- D. Monitor serum glucose levels
Correct Answer: A
Rationale: The correct answer is A: Assess vital signs. Vital signs provide crucial information on the client's overall condition and can help identify any life-threatening issues. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can guide immediate interventions and determine the urgency of further assessments or treatments. Administering oxygen (B) would be appropriate after assessing vital signs. Performing an ECG (C) may be indicated later but is not the priority in this acute situation. Monitoring serum glucose levels (D) is not typically the first assessment in a client with severe abdominal pain.
A nurse is caring for a patient who is post-operative following an abdominal surgery. The nurse should prioritize which of the following interventions?
- A. Encouraging early ambulation to prevent deep vein thrombosis.
- B. Administering pain medication regularly.
- C. Providing wound care and dressing changes.
- D. Encouraging high-protein diet for healing.
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation to prevent deep vein thrombosis. Early ambulation helps prevent blood clot formation in the legs, reducing the risk of deep vein thrombosis post-surgery. It also promotes circulation and aids in preventing complications like pneumonia. Administering pain medication (B) is important, but preventing complications should take priority. Providing wound care (C) is essential but not the top priority. Encouraging a high-protein diet (D) is beneficial for healing, but immediate post-operative mobility is crucial for preventing complications.
Why must a nurse avoid disrupting bloodstains or tears on the clothing of a trauma client?
- A. The clothing is the property of another
- B. It facilitates repair and salvage of the clothing
- C. The clothing is potential evidence with legal implications
- D. It decreases trauma to family members
Correct Answer: C
Rationale: The correct answer is C because the clothing of a trauma client could potentially be considered evidence with legal implications. Preserving the bloodstains or tears on the clothing maintains the integrity of the evidence for forensic investigation or legal proceedings. Disrupting the bloodstains or tears could compromise the evidence and hinder any potential investigation or legal case. Choices A, B, and D are incorrect because the primary concern in this scenario is the legal implications and preservation of evidence, not ownership, repair, salvage, or minimizing trauma to family members.