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: A

Rationale: The correct answer is A: Administer bronchodilators. During an acute asthma attack, the priority is to open the airways quickly to improve breathing. Bronchodilators work rapidly to dilate the constricted airways, providing immediate relief. Corticosteroids are used for long-term management and take time to be effective. Administering morphine is not recommended as it can depress the respiratory system. Performing an ECG is not necessary in the acute management of an asthma attack.

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.

Correct Answer: B

Rationale: Correct Answer: B Rationale: Limiting alcohol intake reduces blood pressure. Reducing sodium intake also helps manage hypertension. Alcohol can increase blood pressure, while sodium can lead to fluid retention. The patient's statement shows understanding of the importance of both factors in managing hypertension. Other Choices: A: Increasing sodium intake worsens fluid retention and hypertension. C: Processed foods are often high in sodium and unhealthy fats, worsening hypertension. D: Reducing exercise can lead to weight gain and increased blood pressure, contrary to managing hypertension.

Correct Answer: C

Rationale: The correct answer is C: Monitor blood pressure. When a client presents with acute abdominal pain, monitoring blood pressure is crucial as it can help assess for potential complications like hypovolemic shock or internal bleeding. Changes in blood pressure may indicate worsening condition and prompt the need for immediate intervention. Monitoring vital signs (A) is important but blood pressure takes precedence in this scenario. Assessing abdominal tenderness (B) is valuable but does not directly address potential life-threatening issues. Monitoring for dehydration (D) is also important but not the most immediate concern in the case of acute abdominal pain.

Correct Answer: D

Rationale: The correct answer is D: Cover the burn site with a clean, dry dressing. This intervention helps protect the burn from infection, promotes healing, and reduces pain. Ice can further damage the skin. Pain medication may be needed but does not address wound care. Maintaining a sterile dressing is crucial, but covering with a clean, dry dressing is more practical and achievable in most settings.

Correct Answer: A

Rationale: The correct answer is A: A trained interpreter. Choosing a trained interpreter ensures accurate communication and confidentiality. Professional interpreters have the necessary language skills and cultural competence to facilitate effective communication between the healthcare provider and the patient. Using a family member (choices B and C) may compromise confidentiality and accuracy due to potential bias or lack of professional training. Similarly, selecting a volunteer university student (choice D) may result in misinterpretation or breach of privacy as they may not have the same level of expertise as a trained interpreter. Ultimately, the most appropriate choice is a trained interpreter to ensure clear and accurate communication while respecting the patient's privacy and dignity.

Correct Answer: C

Rationale: The correct answer is C: explaining progression of the disease to the client and family. This measure helps the client and family understand the disease, leading to better coping and acceptance, thus promoting a positive body image. Administering immune globulin (A) is not directly related to body image. Assessing extremities (B) and heart sounds (D) are important for monitoring the disease but do not directly impact body image.

Correct Answer: A

Rationale: The correct answer is A: Fever. Fever is an early indicator of infection as it is the body's natural response to fighting off pathogens. When the body detects an infection, it raises its temperature to create an inhospitable environment for the pathogens. Pain at the surgical site (B) is common post-operatively but may not necessarily indicate infection. Redness at the incision site (C) can be a sign of inflammation but is not specific to infection. Increased heart rate (D) can occur due to various reasons post-operatively, not just infection. Fever is a systemic response and a more reliable early indicator of infection in this context.