Denise is recovering from an open cholecystectomy. You know that because of the location of the surgery, she has an increased chance of postoperative

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Respiratory complications. After an open cholecystectomy, Denise is at an increased risk of respiratory issues due to the surgical incision's proximity to the diaphragm. The diaphragm plays a crucial role in breathing, and any surgical trauma in that area can lead to decreased lung expansion and potential postoperative complications such as atelectasis or pneumonia. Option A) Myocardial infarction is incorrect because a cholecystectomy does not directly impact cardiac function or blood flow to the heart. The surgery's focus is on the gallbladder and surrounding structures, not the heart. Educationally, understanding the potential postoperative risks of specific surgical procedures is vital for nurses caring for surgical patients. By recognizing the association between a cholecystectomy and respiratory complications, nurses can implement appropriate nursing interventions such as early ambulation, incentive spirometry, and respiratory exercises to prevent respiratory issues and promote optimal recovery. This knowledge enhances patient safety and outcomes postoperatively.

Correct Answer: A

Rationale: The correct nursing treatment for a postoperative patient developing cellulitis in her leg is to keep both her legs elevated as much as possible (Option A). This is essential in managing cellulitis as elevation helps reduce swelling and promotes venous return, aiding in the resolution of inflammation and infection. Encouraging ambulation (Option B) may not be appropriate in this case as excessive movement can worsen the cellulitis and spread the infection. Application of ice (Option C) is contraindicated as it can constrict blood vessels and potentially worsen circulation, which is detrimental in cellulitis treatment. Similarly, applying moisturizing lotion (Option D) is not indicated as it does not address the underlying infection and may even promote bacterial growth due to the moisture. In an educational context, it is crucial for nurses to understand the rationale behind each intervention to provide effective and evidence-based care to their patients. Cellulitis requires a comprehensive approach that focuses on reducing inflammation, promoting proper circulation, and preventing the spread of infection. By selecting the appropriate intervention of leg elevation, nurses can contribute to the successful management of cellulitis and promote optimal patient outcomes.

Correct Answer: C

Rationale: In the context of a patient with a CD4 count less than 200, which indicates severe immunosuppression typically seen in advanced HIV/AIDS, the most crucial nursing assessment would be monitoring for fever (Option C). This is because a low CD4 count puts the patient at high risk for opportunistic infections. Fever is often the first sign of an infection in these patients and can indicate a serious systemic response. Option A, bowel movements, while important for overall health assessment, is not the priority in this case as it does not directly correlate with the patient's immunosuppressed status and infection risk. Option B, urinary output, is also important but does not take precedence over monitoring for signs of infection in a patient with such a low CD4 count. Option D, blood pressure, is not the priority in this situation unless the patient is showing signs of sepsis, which would typically present with a fever. Understanding the priority assessments based on the patient's condition is crucial in providing effective and targeted care in medical-surgical settings, especially in patients with complex health conditions like advanced HIV/AIDS.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Heavy menses or an inadequate intake of iron. Iron deficiency anemia is commonly caused by chronic blood loss, such as heavy menstrual periods, which leads to a decreased iron supply for the body. Option A) Insomnia is unrelated to the development of iron deficiency anemia. Option B) An increase in iron intake would actually be beneficial in preventing iron deficiency anemia, so this option is incorrect. Option D) Low salt intake is not a common cause of iron deficiency anemia. From an educational standpoint, it is important for students to understand the etiology of iron deficiency anemia to provide appropriate care and education to patients. By knowing the causes, nurses can implement interventions such as iron supplementation or dietary changes to help manage and prevent iron deficiency anemia in patients like Anne. This question also reinforces the importance of recognizing common risk factors for iron deficiency anemia in clinical practice.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) The left side of your heart is weakened and is losing the capability to pump blood to your lungs. This is because congestive heart failure typically involves the left side of the heart being unable to effectively pump blood to the rest of the body, causing fluid to back up into the lungs. Option A is incorrect because fluid accumulation in the lungs is not primarily due to the volume of IV fluid administered but rather to the heart's inability to pump effectively. Option B is incorrect as it mentions the right side of the heart, which is not typically associated with fluid accumulation in the lungs in congestive heart failure. Option C is unrelated to the pathophysiology of congestive heart failure and is therefore incorrect. Educationally, understanding the underlying pathophysiology of congestive heart failure is crucial for providing appropriate care and education to patients. By knowing why fluid accumulates in the lungs, healthcare providers can better explain the condition to patients like Tom and help them manage their symptoms effectively. This knowledge also aids in delivering patient-centered care and promoting patient compliance with treatment plans.