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A nurse is caring for a patient who is post-operative following hip replacement surgery. The nurse should prioritize which of the following interventions?
- A. Administering pain medication regularly.
- B. Encouraging early ambulation.
- 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. This is because early ambulation is crucial in preventing complications such as blood clots and muscle atrophy post hip replacement surgery. It helps improve circulation, prevent joint stiffness, and promote healing. Administering pain medication regularly (A) is important but not the top priority. Providing wound care and dressing changes (C) and monitoring for signs of infection (D) are also important but secondary to early ambulation in preventing complications and promoting recovery.
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A nurse is teaching a patient with diabetes about self-management. Which of the following statements by the patient indicates the need for further education?
- A. I will check my blood sugar regularly.
- B. I will take my insulin only when my blood sugar is high.
- C. I will eat a balanced diet and exercise regularly.
- D. I will report any signs of infection to my healthcare provider.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Taking insulin only when blood sugar is high can lead to uncontrolled levels.
2. Regular insulin dosing is essential for diabetes management.
3. Monitoring blood sugar regularly helps in adjusting insulin doses.
4. Eating a balanced diet and exercising are key components of diabetes management.
5. Reporting signs of infection is crucial due to diabetes-related complications.
Which of the following statements best describes the purpose of a health history?
- A. To provide an opportunity for interaction between patient and nurse
- B. To provide a form for obtaining the patient's biographical information
- C. To document the normal and abnormal findings of a physical assessment
- D. To provide a database of subjective information about the patient's past and current health
Correct Answer: D
Rationale: The correct answer is D because a health history aims to gather subjective information about a patient's past and current health. It helps in understanding the patient's health concerns, medical history, lifestyle factors, and other relevant information. By collecting this data, healthcare providers can make informed decisions regarding the patient's care. Option A is incorrect as the purpose is more than just interaction. Option B is incorrect as it focuses solely on biographical information. Option C is incorrect as it pertains to physical assessment findings, not subjective health information.
A nurse is providing education to a patient with chronic liver disease. The nurse should educate the patient to monitor for signs of which of the following complications?
- A. Hypoglycemia.
- B. Hyperglycemia.
- C. Jaundice.
- D. Anemia.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Patients with chronic liver disease are at risk for developing jaundice due to impaired liver function leading to the accumulation of bilirubin. Jaundice is characterized by yellowing of the skin and eyes. Monitoring for jaundice is crucial as it indicates worsening liver function.
Incorrect choices:
A: Hypoglycemia - Not directly related to chronic liver disease, more commonly seen in diabetes.
B: Hyperglycemia - Not typically associated with chronic liver disease unless the patient has underlying diabetes.
D: Anemia - Can be a complication of chronic liver disease, but monitoring for jaundice takes priority due to its direct association with liver dysfunction.
Which of the following responses might the nurse expect during the functional assessment of a patient whose leg is in a cast?
- A. "I broke my right leg in a car accident 2 weeks ago."
- B. "The pain is getting less, but I still need to take Tylenol."
- C. "I check the colour of my toes every evening just like I was taught."
- D. "I'm able to transfer myself from the wheelchair to the bed without help."
Correct Answer: D
Rationale: The correct answer is D because the nurse would expect the patient to demonstrate functional independence in activities like transferring from a wheelchair to the bed despite having a leg in a cast. This response indicates good mobility and strength, which are positive signs of recovery. Choices A, B, and C are incorrect as they do not directly address the functional assessment of the patient. Choice A provides historical information, choice B focuses on pain management, and choice C mentions a self-care routine that is not related to functional ability.
A nurse is caring for a patient who has been diagnosed with asthma. The nurse should educate the patient to avoid which of the following triggers?
- A. Cold, dry air.
- B. Warm, humid air.
- C. Excessive physical activity.
- D. All of the above.
Correct Answer: A
Rationale: The correct answer is A: Cold, dry air. Asthma patients are often triggered by cold, dry air, which can cause airway constriction and worsen symptoms. Warm, humid air can actually help alleviate symptoms by keeping airways moist. Excessive physical activity can also trigger asthma, but it varies among individuals and can be managed with appropriate medication and monitoring. Choice D is incorrect as warm, humid air is not a trigger for asthma.