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A nurse is caring for a patient who is post-operative following an appendectomy. The nurse should prioritize which of the following in the immediate post-operative period?
- A. Administering pain medication.
- B. Encouraging early ambulation.
- C. Monitoring vital signs and fluid status.
- D. Providing wound care and dressing changes.
Correct Answer: C
Rationale: The correct answer is C, monitoring vital signs and fluid status, because it is crucial for assessing the patient's immediate post-operative condition and detecting any signs of complications like hemorrhage or shock. This step ensures early intervention if any issues arise, promoting patient safety and recovery. Administering pain medication (A) is important but not the top priority. Encouraging early ambulation (B) and providing wound care (D) are also essential but come after ensuring the patient's vital signs and fluid status are stable.
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A patient drifts off to sleep when there is no stimulation. The nurse can arouse her easily by calling her name, but she remains drowsy during the conversation. The best description of this patient's level of consciousness would be:
- A. Lethargic.
- B. Obtunded.
- C. Stuporous.
- D. Semialert.
Correct Answer: A
Rationale: The correct answer is A: Lethargic. Lethargic is defined as a state of drowsiness or diminished alertness where the patient can be easily aroused by simple stimuli like calling their name, but they remain drowsy and may drift back to sleep. This patient's ability to be aroused by verbal stimuli and their drowsiness during conversation fits the description of lethargic.
Explanation for other choices:
B: Obtunded - Obtunded refers to a more severe level of decreased consciousness where the patient is difficult to fully arouse and may have limited interactions with the nurse.
C: Stuporous - Stuporous indicates an even deeper state of unconsciousness where the patient requires significant stimulation to be aroused and has minimal responsiveness.
D: Semialert - Semialert would describe a patient who is more responsive than lethargic, showing better awareness of their surroundings and able to maintain a conversation more effectively.
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.
The interview portion of data collection obtains:
- A. Physical data.
- B. Historical data.
- C. Objective data.
- D. Subjective data.
Correct Answer: D
Rationale: The correct answer is D: Subjective data. During the interview portion of data collection, subjective data is obtained as it involves personal opinions, feelings, and experiences shared by the interviewee. This data is based on individual perspectives and cannot be measured objectively. Physical data (A) refers to tangible measurements, historical data (B) relates to past events or records, and objective data (C) is based on observable and measurable facts. In contrast, subjective data (D) captures the interviewee's viewpoints and interpretations, making it the most appropriate choice for the given scenario.
A nurse is caring for a patient with chronic liver disease. The nurse should monitor for signs of which of the following complications?
- A. Jaundice.
- B. Hypoglycemia.
- C. Hyperglycemia.
- D. Anemia.
Correct Answer: A
Rationale: The correct answer is A: Jaundice. In chronic liver disease, impaired liver function can result in the accumulation of bilirubin leading to jaundice. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial in assessing the progression of liver disease.
B: Hypoglycemia is not a common complication of chronic liver disease. Liver plays a role in glycogen storage and glucose production, so hypoglycemia is less likely.
C: Hyperglycemia is more commonly associated with conditions like diabetes rather than chronic liver disease. The liver's role in glucose regulation may be impaired, but hyperglycemia is not a typical complication.
D: Anemia is not directly related to liver disease, although it may occur as a secondary complication due to factors like decreased production of certain blood components. Monitoring for anemia is important, but jaundice is a more specific complication of chronic liver disease.
A nurse is providing discharge instructions to a patient who had a stroke. Which of the following statements by the patient indicates the need for further education?
- A. I will take my medications as prescribed.
- B. I will follow up with my doctor regularly.
- C. I can resume driving after a few weeks of rest.
- D. I will report any sudden changes in my vision or speech.
Correct Answer: C
Rationale: The correct answer is C. After a stroke, patients need to be evaluated by a healthcare professional before resuming driving. This is crucial to ensure the safety of the patient and others on the road. Choice A shows medication compliance, B demonstrates follow-up care, and D emphasizes monitoring symptoms, all of which are essential post-stroke. However, choice C indicates a lack of understanding about the importance of medical clearance before driving, hence the need for further education.