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

Correct Answer: A

Rationale: The correct answer is A: Increased respiratory rate and dyspnea. After a lung resection, complications like atelectasis or pneumonia can occur, leading to respiratory distress. Monitoring respiratory rate and dyspnea helps detect these issues early. Incorrect choices: B: Constipation and abdominal distension are not directly related to post-operative lung resection complications. C: Nausea and vomiting are more likely related to gastrointestinal issues rather than lung resection. D: Muscle weakness and fatigue are not specific signs of complications following a lung resection.

Correct Answer: A

Rationale: The correct answer is A: Inspect for visible pulsation. This is because an arteriovenous fistula for hemodialysis should have a visible pulsation, indicating proper blood flow. Palpating for thrill (B) and auscultating for bruit (C) are also common assessments for an arteriovenous fistula, but inspecting for visible pulsation is the most direct and reliable way to assess the patency of the fistula. Percussing for dullness (D) is not relevant in this context as it does not provide information about the vascular access site.

Correct Answer: B

Rationale: The correct answer is B: Do not use underarm deodorant. This is important because deodorant can interfere with the mammogram results, leading to false readings. It is crucial to have a clean and uncontaminated image for an accurate diagnosis. Choice A is incorrect as it can affect the quality of the mammogram. Choices C and D are irrelevant to the mammography procedure and not necessary instructions for the client.

Correct Answer: D

Rationale: The correct answer is D because crossing arms and legs can indicate defensiveness or discomfort, which may suggest the parent is uneasy discussing their son's treatment. This nonverbal cue could signal a need for empathy and sensitivity in communication. Choice A is incorrect as it overlooks the significance of body language. Choice B assumes comfort without considering the context. Choice C assumes tiredness without considering other possibilities. Understanding body language cues can help in building rapport and addressing concerns effectively.

Correct Answer: C

Rationale: The correct answer is C because the clothing of a trauma client could potentially be considered evidence with legal implications. Preserving the bloodstains or tears on the clothing maintains the integrity of the evidence for forensic investigation or legal proceedings. Disrupting the bloodstains or tears could compromise the evidence and hinder any potential investigation or legal case. Choices A, B, and D are incorrect because the primary concern in this scenario is the legal implications and preservation of evidence, not ownership, repair, salvage, or minimizing trauma to family members.

Correct Answer: B

Rationale: The correct first intervention for a client suspected of having a stroke is to perform a CT scan (Choice B). This is because a CT scan can quickly identify the type of stroke (ischemic or hemorrhagic) and guide treatment decisions. Monitoring neurological status (Choice A) can be important but does not provide a definitive diagnosis. Administering fibrinolytics (Choice C) should only be done after confirming the type of stroke to avoid complications. Performing an MRI (Choice D) is more time-consuming and may not be feasible in the acute setting where quick intervention is crucial. Therefore, a CT scan is the most appropriate initial intervention for a suspected stroke.

Correct Answer: B

Rationale: The correct answer is B: Clanging. Clanging refers to the phenomenon where words are chosen based on sound rather than meaning. In this case, the patient's speech demonstrates a pattern of words that rhyme or have similar sounds, despite lacking coherence or logical connection. This behavior is commonly seen in individuals with conditions like schizophrenia. Incorrect choices: A: Blocking - Blocking refers to sudden interruption or cessation of speech. This does not apply to the scenario described. C: Echolalia - Echolalia involves repetition of words or phrases spoken by others, not self-generated word patterns like in the scenario. D: Neologism - Neologism refers to the creation of new words or phrases with unique meanings, which is not reflected in the patient's speech pattern.

Correct Answer: C

Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.

Correct Answer: A

Rationale: The correct answer is A: Blood urea nitrogen (BUN). In CKD, the kidneys are unable to effectively filter waste products, leading to an increase in BUN levels. Elevated BUN indicates impaired kidney function. Calcium, potassium, and sodium levels may also be affected in CKD, but they are more likely to be imbalanced rather than consistently elevated. Calcium levels may be low due to impaired vitamin D activation, potassium levels may be high due to decreased excretion, and sodium levels can fluctuate based on fluid status. Therefore, while these lab values may be abnormal in CKD, BUN is the most consistently elevated marker of kidney dysfunction.