A nurse is caring for a postoperative patient. Which action should the nurse take to prevent deep vein thrombosis (DVT)?

Correct Answer: D

Rationale: The correct answer is D) Assist the patient with physical therapy. Rationale: 1. **Correct Answer (D):** Physical therapy helps prevent DVT by promoting circulation and preventing blood stasis. Physical activity encourages muscle contractions, which in turn aids in venous return, reducing the risk of clot formation. 2. **Incorrect Answers:** - A) Encouraging early ambulation is important in preventing DVT, but physical therapy involves more structured exercise routines tailored to the patient's needs. - B) While compression stockings can help with DVT prevention, they are not as effective as physical therapy in promoting muscle movement and circulation. - C) Administering aspirin is not primarily used for DVT prevention. Aspirin is more commonly used for its antiplatelet effects in conditions like heart disease. 3. **Educational Context:** - Understanding the importance of preventing DVT postoperatively is crucial for nurses caring for surgical patients. - Physical therapy plays a significant role in preventing complications like DVT in immobile or postoperative patients by promoting mobility and circulation. - Nurses should be knowledgeable about various strategies to prevent DVT and tailor interventions based on individual patient needs to ensure optimal outcomes.

Correct Answer: B

Rationale: In this scenario, the nurse should prioritize option B: Notify the patient's health care provider. This action is crucial because the patient is presenting with symptoms that are indicative of a possible pulmonary embolism, a serious condition that requires immediate medical attention. Contacting the healthcare provider allows for prompt assessment, further diagnostic testing, and initiation of appropriate treatment. Option A (Administer anticoagulant drug therapy) is incorrect because administering medication without a proper diagnosis and healthcare provider's orders can be dangerous and may worsen the patient's condition if the diagnosis is incorrect. Option C (Prepare patient for a spiral CT) is also incorrect as it involves a diagnostic procedure that should be ordered by the healthcare provider after assessment and evaluation. It is not the nurse's role to independently order diagnostic tests. Option D (Elevate the head of the bed to a semi-Fowler's position) is a supportive measure but is not the priority in this situation. The patient's critical condition requires immediate medical intervention. Educationally, this question highlights the importance of prioritizing patient care based on assessment findings and the urgency of the situation. Nurses need to recognize emergent situations, collaborate with healthcare providers, and follow proper protocols to ensure optimal patient outcomes.

Correct Answer: C

Rationale: In this scenario, the priority nursing intervention for a patient receiving chemotherapy and at risk for infection is to administer antifungal therapy (Option C). The rationale behind this is that chemotherapy often suppresses the immune system, making patients more susceptible to fungal infections. Antifungal therapy helps prevent and treat these infections, which can be life-threatening in immunocompromised individuals. Administering antibiotic therapy (Option A) or antibiotics (Option D) may be necessary for bacterial infections, but in this case, the patient is specifically at risk for fungal infections due to chemotherapy. Administering antifungal medication (Option B) is a redundant option as it conveys the same meaning as Option C. Educationally, this question highlights the importance of tailoring interventions to the specific needs of each patient based on their underlying conditions and treatments. Understanding the rationale behind prioritizing certain interventions in different clinical situations is crucial for nurses to provide safe and effective care to their patients, especially those with compromised immune systems.

Correct Answer: B

Rationale: In this scenario, the priority nursing intervention for a patient with a history of myocardial infarction (MI) is to administer a beta-blocker (Option B). The rationale behind choosing a beta-blocker as the correct answer is that it helps reduce the workload on the heart by slowing the heart rate and reducing blood pressure, thereby decreasing myocardial oxygen demand. This is crucial in the context of MI to prevent further damage to the heart muscle. Administering morphine (Option A) may be necessary for pain management in MI, but it is not the priority over stabilizing the patient's cardiovascular status. Administering oral rehydration solutions (Option C) may be important for hydration but does not address the immediate cardiac concern. Administering antiplatelet therapy (Option D) is essential for preventing clot formation in MI, but it is not the priority intervention compared to reducing the heart's workload. From an educational perspective, understanding the rationale behind prioritizing interventions in MI is crucial for nurses to provide effective and timely care to patients experiencing cardiovascular emergencies. Prioritizing interventions based on physiological needs and potential impact on patient outcomes is a fundamental aspect of nursing practice that ensures patient safety and optimal care delivery.

Correct Answer: B

Rationale: The correct answer is B) Administer morphine. In the context of a patient with a history of stroke presenting with weakness and difficulty speaking, these symptoms may indicate the presence of acute pain, possibly related to the stroke. Administering morphine is the priority action to help alleviate the patient's pain and distress, as untreated pain can lead to increased physiological stress and potential complications. Option A) Perform a neurological assessment is important but not the priority in this situation where addressing the patient's immediate distress is crucial. Option C) Monitor respiratory status and Option D) Monitor blood glucose levels are also important aspects of care but are secondary to addressing the patient's acute pain and distress. From an educational standpoint, this question highlights the importance of prioritizing patient care based on immediate needs and symptoms. It emphasizes the need for nurses to quickly identify and address acute issues to ensure patient comfort and prevent potential complications. It also underscores the significance of pain management in improving patient outcomes and quality of care.