A nurse is assessing a patient who is post-operative following a hip replacement. Which of the following is the most important nursing priority after surgery?

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health assessment in nursing test bank Questions

Question 1 of 9

A nurse is assessing a patient who is post-operative following a hip replacement. Which of the following is the most important nursing priority after surgery?

Correct Answer: C

Rationale: The correct answer is C: Preventing deep vein thrombosis (DVT). It is the most important nursing priority after hip replacement surgery because patients are at high risk for DVT due to immobility and altered blood flow. DVT can lead to serious complications like pulmonary embolism. Monitoring for infection (B) is important but preventing DVT takes precedence. Managing pain (A) is essential but not the top priority. Ensuring proper positioning (D) is important for preventing complications, but DVT prevention is more critical post-hip replacement surgery.

Question 2 of 9

Canada's population as a whole is aging, and for the first time in Canadian history, which age group has exceeded that of people aged 15 to 24?

Correct Answer: C

Rationale: The correct answer is C: 55-64 years. This age group has exceeded that of people aged 15-24 due to factors like increased life expectancy, lower birth rates, and the aging baby boomer population. This demographic shift impacts workforce, healthcare, and social services. Choice A is incorrect as it represents the youngest age group. Choice B is incorrect as it falls within the working-age group. Choice D is incorrect as it represents the elderly population, which is still lower than the 55-64 age group in this context.

Question 3 of 9

During an interview, the nurse asks the patient to tell more about their shortness of breath. What is the verbal skill used?

Correct Answer: D

Rationale: The correct answer is D: Open-ended question. This verbal skill allows the patient to provide detailed information and express their feelings freely. By asking the patient to talk more about their shortness of breath, the nurse encourages a comprehensive response. Reflection (A) involves paraphrasing the patient's words, not eliciting more information. Facilitation (B) involves encouraging the patient to continue but does not necessarily prompt open-ended responses. Direct question (C) typically elicits a specific answer and limits the patient's response.

Question 4 of 9

Which of the following responses might the nurse expect during the functional assessment of a patient whose leg is in a cast?

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.

Question 5 of 9

A nurse is about to perform an assessment of a patient's lungs. Which of the following is the most appropriate action before auscultation?

Correct Answer: D

Rationale: The correct answer is D: Ask the patient to lie flat and breathe normally. This position allows for optimal lung expansion, making it easier to hear breath sounds accurately. Asking the patient to lie flat also provides a consistent baseline for comparison across different patients. A: Asking the patient to take deep breaths before auscultation may alter their normal breathing pattern and make it difficult to assess baseline lung sounds accurately. B: Having the patient sit upright can be helpful for certain assessments, but lying flat is preferred for auscultating lung sounds. C: Examining for symmetry is important but not directly related to the optimal position for auscultation.

Question 6 of 9

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?

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.

Question 7 of 9

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?

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.

Question 8 of 9

A 45-year-old woman suffered a head injury in a car accident. A few months after recovering from her injuries, she is unable to differentiate between hot and cold and is unsure of how to dress for the weather. This is an example of:

Correct Answer: B

Rationale: The correct answer is B: Agnosia. Agnosia is the inability to recognize or interpret sensory information, such as temperature or clothing. In this case, the woman's inability to differentiate between hot and cold and dress appropriately for the weather indicates a sensory processing issue, characteristic of agnosia. A: Mania is a mood disorder characterized by extreme excitement and impulsivity, not related to sensory perception issues. C: Dementia is a broad term for cognitive decline, which typically includes memory loss and impaired decision-making, but not necessarily sensory perception deficits. D: Amnestic disorder refers to memory impairment, not the inability to interpret sensory information.

Question 9 of 9

A 75-year-old woman is at the clinic for a preoperative interview. The nurse is aware that the interview with her may take longer than interviews with younger persons. What is the reason for this?

Correct Answer: A

Rationale: The correct answer is A because as people age, they accumulate more life experiences, medical history, and details to share. This can lead to longer conversations during interviews. Choice B is incorrect as not all older adults are lonely and seek conversation. Choice C is incorrect because aging does not necessarily equate to a loss of mental abilities. Choice D is incorrect as hearing loss is not a universal issue among older adults and does not significantly impact the length of interviews.

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