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

Correct Answer: D

Rationale: The correct answer is D: Both B and C. After knee replacement surgery, patients are at risk for developing DVT and pulmonary embolism due to immobility and surgery-related factors. DVT occurs when a blood clot forms in a deep vein, usually in the legs, which can lead to a pulmonary embolism if the clot travels to the lungs. Monitoring for both complications is crucial to prevent serious consequences. Option A, hyperglycemia, is not a common complication following knee replacement surgery and is not directly related to immobility or surgery. Option B, DVT, is correct but does not encompass the risk of pulmonary embolism. Option C, pulmonary embolism, is correct but does not cover the initial risk of DVT formation. Therefore, monitoring for both DVT and pulmonary embolism is essential in post-operative knee replacement patients.

Correct Answer: B

Rationale: The correct answer is B because encouraging early ambulation is a priority post-operative intervention for a patient following a hip replacement. Early ambulation helps prevent complications such as blood clots, muscle weakness, and pneumonia. It also promotes circulation and aids in the patient's recovery. Administering pain medications (A) is important but not the top priority. Monitoring for signs of infection (C) is crucial, but ambulation takes precedence. Providing wound care (D) is essential but can be done after ensuring the patient's mobility.

Correct Answer: B

Rationale: The correct answer is B because cleansing and dressing the wound is crucial in preventing further infection spread. First, cleansing the wound removes debris and pathogens, reducing the risk of infection. Second, dressing the wound protects it from external contaminants. This proactive approach promotes wound healing and prevents complications. A: Notifying the healthcare provider is important, but immediate wound care should be prioritized. C: Applying a dressing without cleansing the wound first may trap bacteria and worsen the infection. D: Pain medications are important for client comfort, but addressing the infection source is necessary for proper healing.

Correct Answer: A

Rationale: The correct answer is A: objective. Objective data refers to measurable and observable information obtained through physical examination or diagnostic tests. In this case, the nurse's documentation of the patient's respirations and pulse rate are objective data as they can be quantified and verified by any healthcare professional. This data is not influenced by personal feelings or interpretations, making it objective. Choice B, reflective, is incorrect as it does not describe the nature of the data provided. Choice C, subjective, is also incorrect because subjective data is based on the patient's feelings or perceptions, which is not the case here. Choice D, introspective, is incorrect as it refers to internal self-reflection, not the nature of the data being documented.

Correct Answer: C

Rationale: The correct intervention for hyperkalemia is to administer insulin (Choice C). Insulin drives potassium into cells, lowering serum potassium levels. This is effective in acutely reducing high potassium levels. Administering calcium gluconate (Choice A) is used for stabilizing cardiac membranes in hyperkalemia but does not lower potassium levels. Sodium bicarbonate (Choice B) is used for metabolic acidosis, not hyperkalemia. Furosemide (Choice D) is a loop diuretic that can lead to potassium loss but is not the primary intervention for hyperkalemia.

Correct Answer: A

Rationale: The correct answer is A: Nursing process. The nursing process consists of systematic steps (assessment, diagnosis, planning, implementation, evaluation) used by nurses to provide individualized care. Assessment helps identify community needs, diagnosis guides problem identification, planning involves setting goals, implementation is about carrying out interventions, and evaluation assesses outcomes. Diagnostic reasoning (B) refers to the process of analyzing data to make clinical decisions, not for planning community care. Critical thinking (C) is a general cognitive process that aids decision-making but is not specific to planning community care. Community care map (D) may be a tool used within the nursing process but is not the overarching framework for planning individualized care.

Correct Answer: A

Rationale: The correct answer is A: Administering diuretics to manage fluid retention. In heart failure, fluid overload can worsen symptoms and lead to complications. Diuretics help reduce excess fluid in the body, relieving strain on the heart. This intervention helps improve cardiac function and alleviate symptoms. Choice B (Encouraging increased physical activity) may be beneficial in some cases, but in heart failure, excessive physical activity can strain the heart further. Choice C (Providing a low-sodium diet) is important in managing heart failure, but diuretics would be more critical initially to address immediate fluid retention. Choice D (Encouraging high-potassium foods) is important for overall health but not the priority in managing heart failure.

Correct Answer: B

Rationale: The main role of the nursing process in community health care is to provide individualized care frameworks. This involves assessing, diagnosing, planning, implementing, and evaluating care tailored to each patient's unique needs. Nursing interventions are personalized based on the individual's health status, preferences, and community resources. This approach promotes holistic and patient-centered care, leading to better health outcomes. The other choices are incorrect because: A: Implementing standardized treatment plans does not account for individual variations and needs. C: Nurses collaborate with diagnostic physicians but do not solely assist them. D: Establishing clinical guidelines is important but not the primary role of the nursing process in community health care.

Correct Answer: A

Rationale: The correct answer is A: Use a numeric pain scale. This method allows for quantitative assessment of pain intensity, aiding in accurate pain management. It is widely used in healthcare settings, providing a standardized way to communicate and monitor pain levels. Visual analog scale (B) is subjective and less precise than numeric scales. Facial expression scale (C) may be influenced by cultural factors and is subjective. Observing for signs of depression (D) is important but not specific to assessing pain intensity.