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: Administer anticoagulants. Anticoagulants are the primary treatment for DVT as they prevent blood clots from getting bigger and reduce the risk of new clots forming. This helps prevent complications like pulmonary embolism. Elevating the leg and applying compression (option B) can help with symptoms but do not address the underlying cause. Providing anticoagulant therapy (option C) is similar to the correct answer but lacks specificity. Applying compression stockings (option D) can help prevent complications but do not treat the existing clot.

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: B

Rationale: The correct answer is B: Alopecia. MOPP therapy for Hodgkin's disease commonly causes hair loss (alopecia), which directly affects body image. This is due to the impact on a person's physical appearance, leading to changes in self-perception and confidence. Cushingoid appearance (A) is a side effect of prolonged corticosteroid use, not typically associated with MOPP therapy. Temporary or permanent sterility (C) and pathologic fractures (D) are potential side effects of other cancer treatments but are not directly related to altering body image.

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: Mammography is used to detect tumors in the breast tissue by taking X-ray images. Tumors can be cancerous or benign, making early detection crucial for treatment. Pain (A) is a symptom, not detected by mammography. Edema (C) is swelling caused by fluid retention, not a primary target of mammography. Epilepsy (D) is a neurological disorder, unrelated to mammography's purpose. Therefore, the correct answer is B.

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: B

Rationale: The correct answer is B because building trust with patients is crucial for effective communication and promoting patient cooperation. Trust takes time to develop and is essential in gaining accurate information about a patient's health. Patients may not disclose all information if they do not trust the nurse. Choice A is incorrect because patients may withhold information for various reasons. Choice C is incorrect as not all patients seeking care may fully understand the Canadian health care system. Choice D is incorrect because not all patients may recognize the importance of answering all questions, especially if they are uncomfortable or lack trust in the healthcare provider.

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.