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.

Correct Answer: B

Rationale: The correct answer is B because asking about future plans post-hospital discharge assesses judgment by evaluating the individual's ability to make considered decisions and anticipate consequences. Choice A focuses on paranoia, not judgment. Choice C assesses interpretation skills, not judgment. Choice D evaluates honesty or ethics, not judgment. Therefore, B is the best choice for assessing judgment.

Correct Answer: C

Rationale: The correct answer is C because using the inhaler every 30 minutes for trouble breathing is not recommended. Overuse can lead to medication side effects and potential worsening of symptoms. A: Holding breath after inhaling helps medication reach lungs. B: Using inhaler before exercise can prevent exercise-induced symptoms. D: Rinsing mouth prevents thrush, a common side effect of inhaled corticosteroids.

Correct Answer: A

Rationale: The correct answer is A because a family history of heart disease, cancer, and diabetes can provide crucial information about potential genetic predispositions and health risks for the patient. This information helps the nurse assess the patient's risk factors and tailor preventative measures or interventions accordingly. Choice B is incorrect as siblings' hobbies and interests are not relevant to the patient's medical history. Choice C is incorrect as the father's occupation does not directly impact the patient's health risks. Choice D is incorrect as the patient's favorite sports team is not relevant to assessing the patient's family history for health-related issues.

Correct Answer: B

Rationale: The correct answer is B: Ambulation as soon as possible after surgery. Ambulation helps prevent complications like blood clots and aids in circulation and muscle strength. Bed rest can lead to stiffness and decrease in range of motion. Limiting physical activity delays recovery. Prolonged use of a cast can hinder mobility and delay rehabilitation.

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.

Correct Answer: A

Rationale: The correct answer is A: Document the findings on the patient's record. This is the appropriate action because documenting the unfamiliar sound ensures that the information is accurately recorded for future reference. Waiting 10 minutes (B) may not address the issue, as the sound could still be present. Asking another nurse to double-check (C) may lead to subjective interpretations. Asking the patient to take deep breaths (D) may not be relevant to identifying the unfamiliar sound. Recording the finding is crucial for tracking changes in the patient's condition and communicating with other healthcare professionals.

Correct Answer: C

Rationale: Rationale for Correct Answer C: - As individuals age, it is normal to experience a slight decline in cognitive abilities, such as response time. - However, general knowledge and abilities are usually well-preserved in older adults. - It is expected that the 75-year-old patient may take a little longer to respond due to age-related changes but should not have a significant decline in general knowledge. Summary of Incorrect Choices: - Choice A is incorrect because it is unrealistic to expect no decrease in any abilities with age. - Choice B is incorrect because while remote memory may decline with age, it is not a universal expectation for all older adults. - Choice D is incorrect as it inaccurately attributes language loss and a decrease in general knowledge to all older adults.

Correct Answer: D

Rationale: The correct answer is D: Papule. A papule is a solid, elevated lesion that is less than 1 cm in diameter. It is circumscribed, meaning it has well-defined borders. Papules are often associated with skin conditions like acne or insect bites. A: Bulla is a large fluid-filled blister, not a solid lesion. B: Wheal is a raised, red area of skin that is typically transient and caused by an allergic reaction. C: Nodule is a solid, elevated lesion that is greater than 1 cm in diameter, not less than 1 cm.