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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 to prevent complications?
- A. Encouraging early ambulation.
- B. Administering pain medication.
- C. Providing wound care and dressing changes.
- D. Monitoring for signs of infection.
Correct Answer: A
Rationale: Correct Answer: A - Encouraging early ambulation
Rationale:
1. Early ambulation helps prevent post-operative complications like blood clots and pneumonia.
2. Movement promotes circulation, aids in lung expansion, and prevents muscle atrophy.
3. It also supports bowel function and helps prevent constipation, a common post-operative issue.
4. Ambulation aids in overall recovery and reduces the risk of complications associated with prolonged immobility.
Other Choices:
B: Administering pain medication - Important for comfort but not the top priority for preventing complications.
C: Providing wound care and dressing changes - Necessary for wound healing but not the immediate priority to prevent complications.
D: Monitoring for signs of infection - Critical but not the primary intervention to prevent complications immediately post-op.
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The nurse is planning health education for a 65-year-old woman who has had a cerebrovascular accident (stroke) and is aphasic. Which of the following is most important to use when assessing mental health in this situation?
- A. Please count back from 100 by sevens.
- B. I will name three items and ask you to repeat them in a few minutes.
- C. Please point to articles in the room and parts of the body as I name them.
- D. What would you do if you found a stamped, addressed envelope on the sidewalk?
Correct Answer: C
Rationale: The correct answer is C: Please point to articles in the room and parts of the body as I name them. This is the most important assessment for mental health in an aphasic patient post-stroke because it evaluates their comprehension, communication abilities, and cognitive function. Pointing to articles and body parts demonstrates understanding and ability to follow instructions, which are crucial aspects of mental health assessment in this context.
A: Please count back from 100 by sevens - This choice involves memory and mathematical abilities, which may not accurately assess mental health in an aphasic patient.
B: I will name three items and ask you to repeat them in a few minutes - This choice tests memory recall, which is not as relevant for assessing mental health in an aphasic patient post-stroke.
D: What would you do if you found a stamped, addressed envelope on the sidewalk? - This choice assesses problem-solving skills, which may not be the most appropriate indicator of mental health in an aphasic patient.
When performing a physical assessment, the first technique the nurse will use is:
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct Answer: B
Rationale: The correct answer is B: Inspection. This is because visual observation is typically the initial step in a physical assessment to gather information about the patient's overall appearance, skin color, posture, and any obvious abnormalities. Palpation (A) involves touching and feeling for abnormalities, which usually follows inspection. Percussion (C) is the technique of tapping on the body to assess underlying structures, and auscultation (D) is listening to sounds produced by the body, both of which typically come after inspection and palpation. Inspecting the patient first allows the nurse to establish a baseline before moving on to more detailed assessment techniques.
A female nurse is interviewing a male patient who is close in age to the nurse. During the interview, the patient makes an overtly sexual comment. The nurse's best response would be:
- A. Stop that immediately!
- B. Oh, you are too funny. Let's keep going with the interview.
- C. Do you really think I'd be interested?
- D. It makes me uncomfortable when you talk that way. Please don't.
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the inappropriate behavior, sets a boundary, and communicates the nurse's discomfort in a professional manner. By stating that the comment makes them uncomfortable and asking the patient to refrain from such behavior, the nurse asserts their professionalism while maintaining respect for both parties. Choice A is too abrupt and may escalate the situation. Choice B dismisses the behavior, which is inappropriate. Choice C could be perceived as confrontational and potentially lead to a defensive response from the patient.
A nurse is teaching a patient with diabetes about blood glucose management. Which of the following statements by the patient indicates proper understanding?
- A. I should check my blood glucose levels regularly and adjust my insulin as needed.
- B. I can stop taking my insulin if my blood glucose is normal.
- C. I should skip meals if my blood sugar is high.
- D. I should only use my insulin when my blood sugar is over 200 mg/dL.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Regular blood glucose monitoring helps in understanding patterns and making informed decisions.
2. Adjusting insulin based on blood glucose levels is crucial for effective diabetes management.
3. This statement shows the patient's understanding of the need for personalized insulin adjustments.
4. It promotes self-management and proactive approach to blood sugar control.
Summary:
B: Stopping insulin abruptly can lead to dangerous complications.
C: Skipping meals can disrupt blood sugar levels and is not recommended.
D: Waiting for high blood sugar to use insulin can result in uncontrolled levels and complications.
A nurse is teaching a patient with asthma about managing an asthma attack. Which of the following statements by the patient indicates proper understanding?
- A. I will use my inhaler every time I feel an asthma attack coming on.
- B. I will wait for the symptoms to subside on their own before using my inhaler.
- C. I will use my inhaler even if I don't feel any symptoms.
- D. I will not use my inhaler if my symptoms are mild.
Correct Answer: A
Rationale: Rationale: Choice A is correct because using the inhaler at the onset of symptoms can help prevent the asthma attack from worsening. This early intervention can be crucial in managing asthma effectively. Waiting for symptoms to subside (Choice B) can be risky as it may delay necessary treatment. Using the inhaler preventively (Choice C) without symptoms is unnecessary and can lead to overuse. Not using the inhaler for mild symptoms (Choice D) can allow the condition to escalate. Thus, Choice A is the most appropriate response for managing an asthma attack effectively.