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: A

Rationale: The correct answer is A: Body systems. This type of assessment promotes critical thinking by organizing data systematically based on different body systems, allowing for clustering of similar data and identification of patterns. Comprehensive assessments (B) may include body systems but lack the focused approach of promoting critical thinking. Head to toe assessments (C) are systematic but may not encourage clustering of data. Emergency assessments (D) prioritize immediate interventions rather than promoting critical thinking or clustering of data.

Correct Answer: A

Rationale: The correct answer is A because broccoli, oranges, and dark greens are rich in essential nutrients like vitamin C, antioxidants, and phytochemicals that boost the immune system and help prevent diseases. Broccoli contains sulforaphane, which has been shown to have anti-cancer properties. Oranges are high in vitamin C, crucial for immune function. Dark greens like spinach and kale are packed with vitamins and minerals that support overall health. Choice B is incorrect because no single food can cure many diseases. Choice C is incorrect because relying solely on vitamin pills may not provide all the necessary nutrients and benefits of whole foods. Choice D is incorrect as there is no scientific evidence supporting the concept of balancing body molecules through food.

Correct Answer: C

Rationale: Step 1: Hypertension is often worsened by high sodium intake. Step 2: Decreasing sodium intake helps lower blood pressure. Step 3: This dietary change aligns with hypertension management. Step 4: Increasing processed foods (A), saturated fats (D), or potassium intake (B) do not directly address the issue of high sodium intake and may even exacerbate hypertension.

Correct Answer: A

Rationale: The correct answer is A: Monitoring blood glucose levels regularly. This is crucial in managing type 2 diabetes because it helps the patient understand how their body responds to food, medication, and activity. By tracking blood glucose levels, the patient can make informed decisions about their diet, medication, and lifestyle choices. This proactive approach enables early detection of fluctuations in blood sugar levels, allowing for prompt adjustments to prevent complications. Summary: - Choice A is correct as monitoring blood glucose levels is essential for managing type 2 diabetes. - Choice B is important but secondary to monitoring blood glucose levels. - Choice C is beneficial for managing diabetes but not as critical as blood glucose monitoring. - Choice D, following a low-carb diet, can be helpful but may not be the most important factor in managing the condition.

Correct Answer: D

Rationale: The correct answer is D: Encourage deep breathing exercises. For a client with a history of asthma and wheezing, deep breathing exercises help improve lung function and reduce the frequency of asthma attacks. These exercises can strengthen respiratory muscles, increase lung capacity, and enhance overall breathing efficiency. Administering bronchodilators (choice A) may provide immediate relief but does not address long-term management. Administering oxygen and encouraging fluid intake (choice B) may be helpful in certain situations but does not specifically target asthma symptoms. Administering corticosteroids (choice C) is typically used for severe asthma exacerbations and should not be the first-line treatment for someone with a history of asthma and wheezing.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. Dehydration and hypotension indicate fluid loss, which can lead to organ damage and shock. Administering IV fluids helps restore blood volume and improve blood pressure. Monitoring blood pressure (B) is important but addressing the underlying issue of fluid loss is crucial. Administering antihypertensive medications (C) would further lower blood pressure, worsening hypotension. Administering diuretics (D) would exacerbate fluid loss, worsening dehydration and hypotension.

Correct Answer: A

Rationale: The correct answer is A: Place the client in a safe environment. This is the primary intervention for a client with a history of falls to prevent further injury. By ensuring the environment is safe, the risk of falls and subsequent injuries is minimized. Choice B, assessing the client's functional status, is important but not the primary intervention. Choice C, encouraging the client to rest, may not address the underlying issue of fall risk. Choice D, encouraging the client to ambulate, may increase the risk of falls for someone with a history of falls. It is crucial to prioritize safety by modifying the environment to prevent falls.

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.