Nokea
A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should prioritize which of the following interventions to prevent complications?
- A. Encouraging early ambulation and use of compression stockings.
- B. Administering pain medication regularly.
- C. Monitoring for signs of infection.
- D. Providing nutritional support and hydration.
Correct Answer: A
Rationale: The correct answer is A. Encouraging early ambulation and use of compression stockings is crucial post-abdominal surgery to prevent complications like deep vein thrombosis and pneumonia. Ambulation helps prevent blood clots and promotes lung expansion. Compression stockings aid in preventing blood pooling in the legs. Administering pain medication regularly (B) is important but not the priority. Monitoring for infection (C) is essential but not the priority immediately post-op. Providing nutritional support and hydration (D) is important but not as critical as preventing immediate complications.
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In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the:
- A. last glaucoma examination.
- B. frequency of breast self-examination.
- C. date of her last electrocardiogram.
- D. limitations related to her involvement in sports activities.
Correct Answer: D
Rationale: The correct answer is D because obtaining information on the limitations related to the girl's involvement in sports activities is crucial for assessing her overall physical health and well-being. This information helps in understanding any potential risks or issues that may arise from her participation in sports. Choices A, B, and C are incorrect as they are not relevant to a review of systems for a healthy 7-year-old girl. Glaucoma examination, breast self-examination frequency, and electrocardiogram date are not typically part of a routine review of systems for a child of her age and health status.
During her prenatal checkup, a patient begins to cry as the nurse asks her about previous pregnancies. The patient says that she is remembering her last pregnancy, which ended in miscarriage. The nurse's best response to her crying would be:
- A. "I'm so sorry for making you cry!"
- B. "I can see that you are sad remembering this. It is all right to cry."
- C. "Why don't I step out for a few minutes until you're feeling better?"
- D. "I can see that you feel sad about this; why don't we talk about something else?"
Correct Answer: B
Rationale: The correct answer is B because it shows empathy and validation towards the patient's emotions. By acknowledging the patient's sadness and giving her permission to cry, the nurse creates a safe and supportive environment. This response helps the patient feel understood and accepted, facilitating emotional expression and potentially leading to a deeper therapeutic relationship.
Choice A is incorrect because it focuses on the nurse's discomfort rather than the patient's feelings. Choice C is incorrect as it may come across as dismissive of the patient's emotions. Choice D is incorrect as it suggests avoiding the topic rather than addressing the patient's feelings directly.
A nurse is teaching a patient with diabetes about managing foot care. Which of the following statements by the patient indicates proper understanding?
- A. I will inspect my feet daily for cuts or blisters.
- B. I will avoid trimming my toenails to prevent injury.
- C. I will wear tight shoes to avoid blisters.
- D. I will ignore any small wounds on my feet.
Correct Answer: A
Rationale: The correct answer is A: "I will inspect my feet daily for cuts or blisters." This statement indicates proper understanding because daily foot inspection is crucial for early detection of any wounds, which can prevent complications in diabetic patients.
Incorrect choices:
B: Avoiding trimming toenails can lead to ingrown nails and potential injury.
C: Wearing tight shoes can increase the risk of blisters and discomfort.
D: Ignoring small wounds can lead to infections and more serious foot issues.
In summary, choice A is correct as it promotes proactive foot care, while the other choices can potentially harm the patient's foot health.
A nurse is providing discharge instructions to a patient with chronic hypertension. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood pressure regularly.
- B. I will take my medication even when my blood pressure is normal.
- C. I can stop taking my medication if I feel fine.
- D. I will avoid high-sodium foods.
Correct Answer: C
Rationale: The correct answer is C because stopping medication without consulting a healthcare provider can lead to uncontrolled hypertension. Choice A shows understanding of monitoring blood pressure, B demonstrates adherence to medication regimen, and D indicates awareness of dietary management. Choice C is incorrect because abruptly stopping medication can have serious health consequences, making further education necessary.
The nurse hears bilateral, louder, longer, and lower pitched tones when percussing over the lungs of a 4-year-old chilWhat should the nurse do next?
- A. Palpate over the area to identify increased pain and tenderness.
- B. Ask the child to take shallow breaths, and percuss over the area again.
- C. Refer the child immediately because of suspicion of an increased amount of air in the lungs.
- D. Consider this a normal finding for a child this age, and proceed with the examination.
Correct Answer: D
Rationale: The correct answer is D because in children, the lung sounds can be different due to their thinner chest walls and more prominent bronchial markings. The louder, longer, and lower-pitched tones heard upon percussion are normal findings in pediatric patients, indicating increased air content in the lungs. Palpating for pain or tenderness (choice A) is not necessary as these findings are expected in children. Asking the child to take shallow breaths and percussing again (choice B) is not needed as the initial findings are normal for the age group. Referring the child immediately (choice C) is unnecessary as these findings are within the normal range for a 4-year-old.