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: Administer corticosteroids. In a client with chest pain and a history of myocardial infarction, the first priority is to address potential inflammation in the myocardium. Corticosteroids help reduce inflammation and stabilize the myocardium, which is crucial in preventing further damage post-myocardial infarction. Administering nitroglycerin (A) is important for vasodilation, but it is typically used after corticosteroids. Morphine (B) and analgesics (C) may provide pain relief but do not address the underlying inflammation. Administering corticosteroids is the most appropriate first step to manage myocardial inflammation and protect the heart tissue.

Correct Answer: B

Rationale: The primary goal for a client with newly diagnosed diabetes is to monitor their blood glucose levels (Answer B). This is essential to understand how their body responds to different foods, activities, and medications. Monitoring blood glucose levels helps in determining the effectiveness of the treatment plan and making necessary adjustments. Teaching the client how to manage their blood glucose levels (Answer A) is important, but monitoring comes first. Monitoring urine output (Answer C) is not as relevant for diabetes management. Administering insulin (Answer D) may be necessary in some cases, but it is not the primary goal initially.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. The priority in a severe allergic reaction is to quickly address the life-threatening symptoms like anaphylaxis. Epinephrine is the first-line treatment as it helps reverse the effects of the allergic reaction by opening airways and increasing blood pressure. Administering antihistamines (choices B and D) can help relieve itching and hives but are not as effective in treating severe symptoms. Monitoring respiratory status (choice C) is important but administering epinephrine takes precedence to stabilize the client's condition.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic hypothesis. Nurses use diagnostic reasoning to formulate diagnostic hypotheses based on patient data and clinical judgment. They analyze symptoms and data to generate potential diagnoses. Choice A, nursing diagnosis, involves identifying patient problems related to nursing care. Choice B, medical diagnosis, is made by physicians to identify diseases or medical conditions. Choice D, diagnostic assessment, refers to the process of collecting and analyzing data to make a diagnosis. Diagnostic hypothesis aligns with the process of diagnostic reasoning in nursing practice.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the client. This is crucial to prevent further damage to the spinal cord. Moving a client with a suspected spinal cord injury can worsen the injury and lead to permanent damage. Immobilizing the client helps maintain spinal alignment and reduces the risk of paralysis. Providing pain relief (B) and loosening clothing (D) are important but secondary actions. Applying pressure to the chest (C) is not recommended for a suspected spinal cord injury as it can also exacerbate the injury.

Correct Answer: A

Rationale: The correct answer is A because reinforcing good habits, such as healthy eating and exercise, is essential for promoting health and preventing disease. This involves educating patients on proper self-care practices. Providing medical diagnosis (B) is not a nursing role, as it falls under the domain of medical professionals. Maintaining optimal functioning (C) is important but not specific to promoting health. Prescribing treatment (D) is beyond the scope of nursing practice, as only advanced practice nurses have prescriptive authority.

Correct Answer: B

Rationale: The correct answer is B: gout. Uric acid levels are typically checked for gout, a type of arthritis caused by the buildup of uric acid crystals in the joints. This condition directly relates to uric acid levels in the blood. Asthma (choice A), diverticulitis (choice C), and meningitis (choice D) do not typically require checking uric acid levels. Asthma is a respiratory condition, diverticulitis is a gastrointestinal condition, and meningitis is an inflammation of the protective membranes covering the brain and spinal cord.

Correct Answer: B

Rationale: The correct answer is B: Deep vein thrombosis (DVT). Patients with a history of stroke are at increased risk for DVT due to immobility and potential damage to blood vessels. The nurse should monitor for signs such as swelling, pain, and redness in the extremities. Pneumonia (A) can occur post-stroke but is not the most common complication. Hypoglycemia (C) is more relevant for diabetic patients. Hypertension (D) is a common comorbidity in stroke patients but monitoring for DVT is crucial due to its immediate life-threatening implications.