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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.
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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.
A nurse is caring for a patient with a history of asthma. The nurse should monitor for which of the following complications?
- A. Pneumonia.
- B. Respiratory failure.
- C. Anemia.
- D. Hyperglycemia.
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Asthma is a chronic respiratory condition that can lead to respiratory failure if not managed properly. The nurse should monitor for signs of worsening asthma symptoms such as increased respiratory rate, accessory muscle use, and decreased oxygen saturation. Pneumonia (A) is a possible complication but is not directly related to asthma. Anemia (C) and Hyperglycemia (D) are not typically associated with asthma and would not be the primary complications to monitor for in this case.
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The nurse should prioritize which of the following interventions?
- A. Administering supplemental oxygen as needed.
- B. Encouraging regular physical activity.
- C. Administering antibiotics regularly.
- D. Providing increased fluid intake.
Correct Answer: A
Rationale: The correct answer is A: Administering supplemental oxygen as needed. This is the priority intervention for a patient with COPD because it helps improve oxygenation and relieve respiratory distress, which is the main concern in COPD. Supplemental oxygen also helps reduce the workload on the heart and other organs. Encouraging physical activity (B) is important for overall health but may not be the priority in acute exacerbations. Administering antibiotics regularly (C) is not necessary unless there is a documented infection. Providing increased fluid intake (D) is important for maintaining hydration but is not the priority intervention in this case.
A nurse is caring for a patient with hypertension. Which of the following lifestyle changes would the nurse prioritize to help manage the patient's blood pressure?
- A. Increasing sodium intake.
- B. Losing weight and increasing physical activity.
- C. Consuming more processed foods.
- D. Limiting fluid intake.
Correct Answer: B
Rationale: The correct answer is B. Losing weight and increasing physical activity help manage blood pressure by reducing excess body weight, improving heart function, and enhancing blood flow. This leads to lower blood pressure levels.
A: Increasing sodium intake would worsen hypertension by promoting fluid retention and raising blood pressure.
C: Consuming more processed foods often includes high levels of sodium, unhealthy fats, and additives that can negatively impact blood pressure.
D: Limiting fluid intake is not a primary lifestyle change for managing hypertension; adequate fluid intake is important for overall health and blood pressure regulation.
A nurse is caring for a patient who is post-operative following hip replacement surgery. Which of the following should be included in the nursing care plan to prevent complications?
- A. Encouraging the patient to avoid physical activity for several weeks.
- B. Administering pain medication only when requested by the patient.
- C. Monitoring the patient for signs of infection and deep vein thrombosis.
- D. Providing education on safe lifting techniques.
Correct Answer: C
Rationale: The correct answer is C because monitoring the patient for signs of infection and deep vein thrombosis is crucial in preventing complications post-hip replacement surgery. Infections can lead to serious complications, while deep vein thrombosis can result in blood clots that can be life-threatening. By closely monitoring for these signs, the nurse can intervene early and prevent further complications.
Choice A is incorrect because complete avoidance of physical activity can lead to other complications such as muscle atrophy and delayed recovery. Choice B is incorrect because pain management should be proactive to prevent unnecessary suffering. Choice D, while important, is not directly related to preventing complications such as infection and deep vein thrombosis.