A nurse is caring for a patient who is post-operative following abdominal surgery. The nurse should monitor for which of the following complications?

Correct Answer: D

Rationale: The correct answer is D: Atelectasis and pneumonia. Following abdominal surgery, patients are at risk for atelectasis (lung collapse) due to shallow breathing and pneumonia due to impaired lung function. A nurse should monitor for signs such as decreased oxygen saturation, increased respiratory rate, and crackles on auscultation. Wound infection (A) is a common post-operative complication but not specific to abdominal surgery. Hyperglycemia (B) may occur due to stress response but is not directly related to abdominal surgery. Dehydration (C) is a concern post-operatively, but respiratory complications like atelectasis and pneumonia are higher priority due to potential life-threatening consequences.

Correct Answer: D

Rationale: The correct answer is D: sodium chloride. Intestinal suctioning in a client with an ileus leads to loss of fluids rich in sodium chloride. This loss can result in electrolyte imbalances and dehydration. Calcium (A), magnesium (B), and potassium (C) are not typically lost in significant amounts through intestinal suctioning in the context of an ileus. Therefore, sodium chloride is the most likely electrolyte to be lost in this scenario.

Correct Answer: B

Rationale: The correct answer is B: assess for middle ear infection as a possible cause. Sensorineural hearing loss is usually caused by damage to the inner ear or the nerve pathway to the brain. Middle ear infection can sometimes lead to conductive hearing loss, but it's important to rule out this possibility during assessment. Speaking loudly (A) is not effective for sensorineural hearing loss. Asking about medications (C) may be relevant but not as crucial as assessing for a possible cause. Looking for external ear obstruction (D) is more relevant for conductive hearing loss, not sensorineural.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. The nurse's first priority is to address pain and ensure the client's comfort and well-being. Pain relief helps reduce distress, improve communication, and prevent complications. Monitoring blood pressure (B) and providing hydration (C) are important but not the immediate priority in severe trauma. Administering a blood transfusion (D) may be necessary but is not the first priority compared to addressing pain and stabilizing the client.

Correct Answer: A

Rationale: The correct answer is A: Administer glucose. When caring for a client with suspected hypoglycemia, the first priority is to raise their blood sugar levels quickly to prevent potential complications such as seizures or loss of consciousness. Administering glucose helps to rapidly increase blood sugar levels and alleviate symptoms. The other choices (B: Administer insulin, C: Place the client in a supine position, D: Administer IV fluids) are incorrect because administering insulin can further lower blood sugar levels, placing the client in a supine position may not address the immediate issue of low blood sugar, and administering IV fluids does not directly address the hypoglycemia.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. During an acute asthma attack, bronchodilators are the first-line treatment to quickly relieve bronchospasm and improve airflow. They work by relaxing the muscles around the airways, allowing the client to breathe easier. Administering corticosteroids (choices B and C) is important but typically done after bronchodilators to reduce airway inflammation. Encouraging fluid intake (choice D) is not the priority in an acute asthma attack, as the focus should be on addressing the breathing difficulty promptly.

Correct Answer: A

Rationale: The correct answer is A: Hyperkalemia. In CKD, the kidneys are unable to effectively excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac complications. Hyperkalemia is a common and critical complication in CKD patients. B: Hypokalemia is unlikely in CKD as the kidneys typically retain potassium. C: Hyperglycemia is more commonly associated with diabetes rather than CKD. D: Hypercalcemia is not a common complication of CKD; in fact, CKD often leads to lower calcium levels due to impaired activation of vitamin D.

Correct Answer: B

Rationale: The correct answer is B: Administering oxygen as prescribed. Oxygen therapy is a critical intervention in pneumonia to improve oxygenation and prevent hypoxia. Priority is given to interventions that address the immediate physiological needs of the patient. Encouraging fluid intake (A) is important but not as urgent as oxygen therapy. Encouraging ambulation (C) can be beneficial for overall health but may not be suitable for a patient with pneumonia. Providing pain medication (D) is important for comfort but is not the priority in this case.

Correct Answer: A

Rationale: The correct first step in managing a client with acute renal failure is to administer IV fluids (Choice A). This is crucial to ensure adequate hydration and maintain renal perfusion. By administering IV fluids, you can help improve kidney function and prevent further damage. Monitoring urine output (Choice B) is important but comes after addressing the fluid balance with IV fluids. Performing a CT scan (Choice C) is not typically the initial step in managing acute renal failure as it does not directly impact the patient's immediate condition. Administering diuretics (Choice D) can worsen the condition by further reducing kidney function, so it is not the recommended first step.