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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 interventions?
- A. Administering antiemetics as needed.
- B. Encouraging early ambulation to prevent complications.
- C. Providing wound care and dressing changes.
- D. Monitoring for signs of infection.
Correct Answer: B
Rationale: The correct answer is B: Encouraging early ambulation to prevent complications. Early ambulation after abdominal surgery helps prevent postoperative complications like deep vein thrombosis and pneumonia. It promotes circulation, aids in bowel function, and reduces the risk of atelectasis. Encouraging the patient to move also helps with pain management and overall recovery.
Choice A: Administering antiemetics as needed. While addressing nausea and vomiting is important, it is not the top priority in this case.
Choice C: Providing wound care and dressing changes. Wound care is crucial, but ensuring early ambulation takes precedence to prevent complications.
Choice D: Monitoring for signs of infection. While monitoring for infection is essential, promoting early ambulation is a proactive measure to prevent various complications and enhance recovery.
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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.
A 35-year-old pregnant woman comes to the clinic for her monthly appointment. During assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment aware that another finding may be:
- A. Keratosis.
- B. Mitoasma.
- C. Linea nigra.
- D. Linea gravida.
Correct Answer: C
Rationale: The correct answer is C: Linea nigra. This is a common finding during pregnancy due to hormonal changes causing hyperpigmentation on the abdomen. The other choices are incorrect because keratosis refers to a skin condition characterized by rough, scaly patches; melasma is a condition causing dark patches on the skin, often due to hormonal changes; and linea gravida is not a recognized term in dermatology. Therefore, based on the context of the patient being pregnant and presenting with hyperpigmentation on her face, the most likely finding would be Linea nigra, a dark line that runs from the navel to the pubic bone during pregnancy.
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.
A patient tells the nurse that she believes in "the hot"“cold theory, where illness is caused by hot or cold entering the body." Which of the following responses from the nurse would be most appropriate?
- A. I do not believe in this theory, but tell me about it.
- B. I know that this is your belief, but the cause is actually a virus.
- C. I did not take this in school, so it's unfamiliar to me.
- D. I have not heard of this theory. Tell me more.
Correct Answer: D
Rationale: The correct answer is D because it shows respect for the patient's belief and promotes open communication. By asking the patient to explain more about the hot-cold theory, the nurse acknowledges the patient's perspective and builds a trusting relationship. Option A dismisses the patient's belief, risking alienation. Option B is informative but misses the opportunity to understand the patient's cultural beliefs. Option C is unprofessional and does not address the patient's concerns.
A nurse is caring for a patient with chronic kidney disease. The nurse should monitor for which of the following signs of fluid overload?
- A. Shortness of breath and weight gain.
- B. Increased urine output and fatigue.
- C. Dizziness and hypotension.
- D. Nausea and vomiting.
Correct Answer: A
Rationale: The correct answer is A, shortness of breath and weight gain, because fluid overload in patients with chronic kidney disease can lead to pulmonary edema and weight gain due to retained fluid. Shortness of breath occurs as the excess fluid accumulates in the lungs. Increased urine output and fatigue (B) are more indicative of dehydration. Dizziness and hypotension (C) are symptoms of hypovolemia, not fluid overload. Nausea and vomiting (D) are nonspecific symptoms and not typically associated with fluid overload.