A nurse is caring for a patient who is post-operative following abdominal surgery. Which of the following signs and symptoms would the nurse consider as an early indicator of infection?

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.

Correct Answer: A

Rationale: The correct answer is A: Bleeding. Warfarin is an anticoagulant medication that works by inhibiting blood clotting factors. Monitoring for signs of bleeding is crucial as warfarin increases the risk of bleeding events. Signs of bleeding may include easy bruising, nosebleeds, blood in urine or stool. Hypertension (B), hyperglycemia (C), and hypokalemia (D) are not direct effects of warfarin. Monitoring for these conditions may be important for other medications or conditions, but they are not the primary concern when a patient is prescribed warfarin.

Correct Answer: C

Rationale: The correct answer is C: "I can stop taking my medication if I feel fine." This statement indicates a misunderstanding of the importance of medication adherence in managing heart failure. Here's the rationale: 1. Patients with heart failure often require lifelong medication to control symptoms and prevent complications. 2. Stopping medication abruptly can lead to worsening of heart failure symptoms and potential health risks. 3. Monitoring for symptoms is essential, but it does not replace the need for consistent medication use. Other choices are incorrect because: A is correct as daily medication adherence is crucial. B is correct as reducing sodium intake helps manage fluid retention in heart failure. D is correct as daily weight monitoring helps detect fluid retention early.

Correct Answer: B

Rationale: The correct answer is B: Provide a source of fast-acting carbohydrate. In hypoglycemia, the priority is to raise blood glucose levels quickly to prevent complications like seizures or loss of consciousness. Fast-acting carbs like juice or glucose tablets are the first-line treatment. Administering insulin (choice A) would lower blood sugar further. Administering an oral hypoglycemic agent (choice C) takes time to work and is not suitable for emergencies. Monitoring blood pressure (choice D) is important but not the priority in this situation.

Correct Answer: A

Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial for patients with diabetes and peripheral neuropathy to prevent complications like infections and ulcers. By inspecting their feet daily, the patient can identify any injuries or abnormalities early and seek prompt medical attention. This proactive approach can help prevent serious consequences such as amputations. Summary of incorrect choices: B: Taking medications only when experiencing symptoms - This is not recommended as medications for diabetes and neuropathy are often prescribed to prevent complications and manage the conditions on a daily basis. C: Exercising to increase foot circulation - While exercise is beneficial, patients with peripheral neuropathy may have decreased sensation in their feet, increasing the risk of injury during exercise. D: Wearing tight-fitting shoes to avoid blisters - Tight-fitting shoes can cause pressure points and increase the risk of foot injuries, especially in patients with neuropathy.