A nurse is caring for a patient who is post-operative following a total knee replacement. The nurse should prioritize which of the following interventions?

Correct Answer: A

Rationale: The correct answer is A: Encouraging early ambulation. This is a priority intervention because early ambulation helps prevent complications such as blood clots and respiratory issues. It also promotes circulation and aids in the recovery process. Administering pain medication (B) is important but not the top priority. Providing wound care and dressing changes (C) is necessary but can be done after ensuring the patient's mobility. Monitoring for signs of infection (D) is also crucial, but promoting early ambulation takes precedence in this scenario to prevent complications.

Correct Answer: B

Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. This is because in hypoglycemia, the patient's blood sugar levels are low and need to be raised quickly to avoid serious complications like seizures or loss of consciousness. Fast-acting carbohydrates, such as glucose tablets or juice, can rapidly increase blood sugar levels. Administering insulin (choice A) would further lower blood sugar levels, monitoring without intervention (choice C) could lead to worsening symptoms, and administering an oral hypoglycemic agent (choice D) may not act quickly enough to raise blood sugar levels in an emergency situation.

Correct Answer: A

Rationale: The correct first action for a nurse when caring for a client with acute shortness of breath is to administer oxygen (Choice A). Oxygen is essential to support the client's respiratory function and improve oxygenation. Administering corticosteroids (Choice B) may be considered later for certain underlying conditions, but oxygen takes precedence. Administering pain relief (Choice C) is not the priority in this situation. Placing the client in a supine position (Choice D) can potentially worsen respiratory distress in some cases, making it an incorrect choice.

Correct Answer: B

Rationale: The correct answer is B: Place the client in a supine position. This is the first step when administering Heparin to prevent bleeding or bruising at the injection site. Placing the client in a supine position helps reduce the risk of injury and promotes optimal absorption. Administering antipyretics (Choice A) is not the first step in administering Heparin. Administering insulin (Choice C) is unrelated to Heparin administration. Monitoring vital signs (Choice D) is important but typically done after the initial step of positioning the client correctly.

Correct Answer: A

Rationale: The correct answer is A: Administer thrombolytics. Thrombolytics help dissolve blood clots causing the stroke, restoring blood flow to the brain. This intervention is time-sensitive to prevent further brain damage. Administering aspirin (B) is important but not the priority over thrombolytics. Performing an ECG (C) assesses heart function, not the immediate intervention for stroke. Administering corticosteroids (D) is not indicated in acute stroke management.

Correct Answer: C

Rationale: The correct answer is C, stab wound to the chest. This injury is the highest priority because it poses the greatest risk to the client's life due to potential damage to vital organs and major blood vessels. Immediate intervention is crucial to prevent severe bleeding, pneumothorax, or cardiac tamponade. Treating this injury promptly can significantly increase the client's chances of survival. The other choices are incorrect because: A: An open leg fracture, while serious, does not typically pose an immediate life-threatening risk compared to a stab wound to the chest. B: An open head injury can be severe, but not all head injuries are immediately life-threatening. D: Traumatic amputation of a thumb, while traumatic and painful, is not a priority compared to injuries that directly threaten a client's life.

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. In an 11-12-month-old child, the inability to pull to a standing position may indicate developmental dysplasia of the hip (DDH) as it can lead to abnormal hip development. Refusal to walk (A) can be a sign of other musculoskeletal issues but not specific to DDH. Negative Trendelenburg sign (C) refers to weakness in the hip abductors and is not a specific finding for DDH. A negative Ortolani sign (D) indicates the absence of hip dislocation and is not a definitive sign of DDH at this age.

Correct Answer: D

Rationale: The correct answer is D because the older adult's statement about joining his wife in heaven and plan to shoot himself indicates clear intent and imminent risk. This individual has a specific plan and timeframe, making them highest risk. Choice A is incorrect because joking about death does not necessarily indicate an imminent risk of suicide. Choice B is incorrect as past suicide attempts are a risk factor, but immediate intent is more concerning. Choice C is incorrect as the adolescent's statement is concerning, but there is no specific plan or timeframe mentioned, lowering the immediate risk compared to choice D.

Correct Answer: D

Rationale: The correct answer is D: To treat human responses. This goal aligns with the nursing profession's focus on addressing the holistic needs of individuals. Nurses aim to understand and manage patients' emotional, physical, and psychological responses to illness or treatment. By treating human responses, nurses can improve overall well-being. A: Providing cost-effective care is important but not a broad goal within nursing. It is a component of efficient healthcare delivery. B: Forming broad nursing diagnoses is a part of the nursing process, not a broad goal in itself. C: Promoting self-care is crucial in nursing practice, but it is more of a specific intervention rather than a broad goal encompassing the entire profession.