A nurse is assessing a postoperative patient and notes that the surgical site is red, swollen, and warm to the touch. What should the nurse do first?

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Oxygenation NCLEX Questions with Rationale Questions

Question 1 of 5

A nurse is assessing a postoperative patient and notes that the surgical site is red, swollen, and warm to the touch. What should the nurse do first?

Correct Answer: B

Rationale: The correct answer is B: Notify the healthcare provider. The symptoms described suggest signs of infection at the surgical site, which requires immediate attention by the healthcare provider. In this situation, the nurse should prioritize notifying the healthcare provider to ensure prompt assessment and appropriate intervention. Checking the patient's temperature (choice A) may provide additional information but does not address the immediate need for intervention. Administering pain medication (choice C) may temporarily alleviate symptoms but does not address the underlying issue of infection. Performing a neurological exam (choice D) is not indicated based on the symptoms described.

Question 2 of 5

A nurse is caring for a patient who is recovering from surgery and is complaining of pain. What is the priority action?

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. The priority action is to address the patient's immediate need, which is pain control to ensure comfort and promote recovery. Administering pain relief is crucial for patient well-being post-surgery. Choice B is incorrect as a bronchodilator is not indicated for pain management. Choice C is also incorrect as monitoring blood glucose levels is not the priority for a patient complaining of pain post-surgery. Choice D is a duplicate answer and does not provide any additional information.

Question 3 of 5

A nurse is caring for a patient with asthma who is experiencing shortness of breath. What is the priority nursing intervention?

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help to open the airways quickly, providing immediate relief for the patient's shortness of breath in an acute asthma attack. This intervention addresses the patient's current distress and helps improve oxygenation. Administering corticosteroids (choice B) is important for long-term management but not the priority in an acute situation. Monitoring vital signs (choice C) is essential but not the immediate priority when the patient is in respiratory distress. Administering insulin (choice D) is not indicated for asthma and would not address the patient's shortness of breath.

Question 4 of 5

Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

Correct Answer: D

Rationale: Measuring induration is a simple task within UAP scope, unlike assessing lung sounds or teaching.

Question 5 of 5

Teach the patient about the use of expectorants.

Correct Answer: C

Rationale: Expectorants help loosen mucus in the airways, which is relevant for pneumonia patients with ineffective airway clearance. Rinsing the mouth after inhalers prevents oral thrush, a common issue with inhaled corticosteroids.

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