The INITIAL priority assessment performed by the nurse, when admitting a patients the unit after abdominal surgery is to check for ______.

Correct Answer: D

Rationale: When admitting a patient to the unit after abdominal surgery, the initial priority assessment performed by the nurse should focus on assessing the patient's respiratory function and airway. This is crucial because post-surgical patients are at risk for complications such as respiratory depression, atelectasis, and airway obstruction. Monitoring the patient's breathing pattern, oxygen saturation levels, and ensuring a patent airway are essential in preventing respiratory distress or failure. Prompt assessment and intervention in this area can help prevent respiratory complications and ensure the patient's safety and well-being. Once the patient's respiratory status is stable, the nurse can then proceed to assess other aspects such as the surgical site, skin color, temperature, and responsiveness to stimuli.

Correct Answer: C

Rationale: The patient is presenting with sudden onset weakness and numbness on one side of the body, along with difficulty speaking and understanding speech, which are typical symptoms of a stroke. Imaging revealing an acute infarction involving the left middle cerebral artery territory is consistent with an ischemic stroke. Ischemic stroke occurs when there is a blockage in a blood vessel supplying blood to the brain, leading to a lack of oxygen and nutrients to the affected area, resulting in neurological deficits. This is in contrast to an intracerebral hemorrhage, which is caused by bleeding into the brain tissue, or a subarachnoid hemorrhage, which involves bleeding into the space surrounding the brain. A transient ischemic attack (TIA) is a temporary episode of neurological dysfunction caused by a brief blockage of blood flow to a part of the brain, usually resolving within 24 hours. In this case, the presentation and imaging findings are most

Correct Answer: C

Rationale: The priority item that should be placed at the newborn's bedside is a blood pressure cuff. Monitoring the newborn's blood pressure is crucial in the NICU, as it helps assess the baby's cardiovascular function and overall well-being. Blood pressure changes can be an early indication of potential health issues, so having a blood pressure cuff readily available allows for timely monitoring and intervention if necessary. The other items listed (specific gravity urinometer, rectal thermometer, bottle of sterile normal saline) are also important in neonatal care, but monitoring blood pressure takes precedence in this scenario.

Correct Answer: C

Rationale: For managing a conscious patient with a dislocated shoulder, the appropriate action is to provide analgesia to help manage the pain and discomfort associated with the dislocation. Applying ice packs to the affected shoulder can also help reduce swelling and provide some relief. It is important to refrain from attempting to reduce the dislocation by pulling on the affected arm, as this can cause further damage and worsen the injury. Applying a splint to immobilize the arm in the dislocated position is also not recommended, as this can lead to complications and hinder the reduction process. Administering intravenous fluids to prevent dehydration is not directly related to managing a dislocated shoulder in a conscious patient.

Correct Answer: A

Rationale: Developing a routine with the patient to balance her studies and rest needs is the most appropriate intervention to promote rest. This approach considers the patient's responsibilities and can help her organize her time effectively to ensure she gets adequate rest while managing her studies. It acknowledges the importance of rest without completely disregarding the patient's other commitments, ultimately fostering a balanced approach to self-care. This intervention is patient-centered and collaborative, empowering the patient to take an active role in prioritizing rest alongside her educational responsibilities.

Correct Answer: D

Rationale: Cooking foods in a variety that includes meat, dairy products, and beans demonstrates a positive coping index for the family in addressing the protein deficiency and malnutrition in their children. This behavior shows the family's understanding and effort to provide diverse sources of protein, which is essential for addressing protein deficiency. By including different protein-rich foods in their meals, the family is actively working towards improving the nutritional status of their children. This approach aligns with the goal of health education to change knowledge, attitudes, and practices to enhance individual, family, and community health.

Correct Answer: B

Rationale: The most appropriate action for Nurse Pedrito to take at this time is to explore the reason for Mang Emilio's refusal to take his daily medication for hypertension. By understanding the underlying cause of his refusal, Nurse Pedrito can address any concerns or barriers that may be preventing Mang Emilio from adhering to his medication regimen. This approach emphasizes the importance of patient-centered care and communication in promoting medication compliance and overall health outcomes. Additionally, it allows Nurse Pedrito to work collaboratively with Mang Emilio to find a solution that meets his needs and preferences.

Correct Answer: D

Rationale: When the anesthesiologist visits a patient to explain the anesthesia for surgery, the most likely type of anesthesia to be ordered in this scenario would be general anesthesia. General anesthesia is a state of controlled unconsciousness where the patient is completely unaware and unresponsive during the procedure. This type of anesthesia is typically used for surgeries that are more complex, lengthy, or invasive, requiring the patient to be completely still and asleep throughout the operation.

Correct Answer: C

Rationale: Assessing the patient for respiratory distress is the important nursing intervention that must be done in this situation. The scenario provided indicates that the patient with chronic obstructive pulmonary disease (COPD) is experiencing increased work of breathing, which puts them at risk for respiratory distress. It is crucial for the nurse to monitor the patient's respiratory status closely, including assessing their oxygen saturations, respiratory rate, and effort, to identify any signs of respiratory distress early and intervene promptly. This proactive assessment can help prevent further deterioration of the patient's condition and ensure appropriate nursing interventions are implemented promptly.