What is the most appropriate intervention for a client with severe nausea and vomiting after surgery?

Correct Answer: A

Rationale: The correct answer is A: Administer antiemetics. This intervention helps to reduce nausea and vomiting by blocking the neurotransmitters responsible for triggering these symptoms. Administering antiemetics is the most direct and effective approach to address severe nausea and vomiting post-surgery. Choice B (Placing the client in a supine position) is incorrect because it does not directly address the underlying cause of nausea and vomiting. Choice C (Providing hydration) is important but may not alleviate the symptoms of severe nausea and vomiting. Choice D (Monitoring bowel sounds) is important for assessing gastrointestinal motility but does not directly address the immediate symptoms of nausea and vomiting.

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. At 11-12 months, a child should be able to pull themselves to a standing position. Inability to do so suggests possible hip joint instability, a key risk factor for developmental dysplasia of the hip. Refusal to walk (A) is not specific to hip dysplasia. Negative Trendelenburg sign (C) indicates good hip abductor strength, which is not a risk factor. Negative Ortolani sign (D) is a maneuver used for hip joint assessment in infants and is not indicative of hip dysplasia risk at this age.

Correct Answer: C

Rationale: The correct answer is C: Monitor the client's blood pressure. When a client develops a fever after surgery, it could indicate various causes, including infection or inflammatory response. Monitoring blood pressure is essential to assess circulatory status, as fever can lead to increased heart rate and decreased blood pressure. Administering antibiotics (choice A) should only be done if infection is confirmed. Monitoring temperature and assessing for infection (choice B) is important but not the immediate priority. Administering fluid resuscitation (choice D) may be necessary based on the client's overall condition but should be guided by monitoring blood pressure.

Correct Answer: A

Rationale: The correct answer is A: Increasing physical activity and managing weight. This is important for stroke prevention as exercise can improve cardiovascular health and help maintain a healthy weight, reducing the risk of another stroke. Increasing sodium intake (B) can actually elevate blood pressure, increasing stroke risk. Avoiding physical activity (C) can lead to a sedentary lifestyle, which is detrimental to stroke prevention. Consuming high-calorie, high-fat foods (D) can contribute to obesity and other risk factors for stroke. Prioritizing physical activity and weight management aligns with evidence-based guidelines for stroke prevention.

Correct Answer: B

Rationale: The correct answer is B: Body Image Disturbance. Infertility can impact one's perception of self and body image, leading to feelings of incompleteness. This nursing diagnosis addresses the emotional distress related to altered self-perception. A: Risk for Self Harm is not directly related to the client's statement about feeling incomplete due to infertility. C: Ineffective Role Performance doesn't specifically address the client's feelings of incompleteness related to infertility. D: Powerlessness may not fully capture the client's emotional struggle with their body image and feelings of incompleteness due to infertility.

Correct Answer: D

Rationale: The correct answer is D: Colace. When a client is immobilized and experiencing constipation, a stool softener like Colace is appropriate to prevent straining and discomfort. Advil and Anasaid are pain relievers, not laxatives. Clinocil is not a recognized medication. Colace is the best choice to address constipation in this scenario.

Correct Answer: C

Rationale: The correct answer is C, BMI indicates obesity (35). To calculate BMI, we use the formula BMI = (Weight in pounds / (Height in inches x Height in inches)) x 703. Plugging in the values (216 / (66 x 66)) x 703, we get a BMI of approximately 35. A BMI of 35 falls within the obesity category (BMI 30 or higher). Choice A is incorrect because a BMI of 35 is not within normal limits. Choice B is incorrect as a BMI of 27 would indicate overweight status, not obesity. Choice D is incorrect as the BMI calculated is higher than normal, not lower.

Correct Answer: A

Rationale: Administering aspirin is the most appropriate intervention for a client experiencing a heart attack. Aspirin helps prevent blood clot formation, which is crucial in reducing further damage to the heart during a heart attack. It inhibits platelets from clumping together, improving blood flow to the heart muscle. Thrombolytics are used to dissolve existing blood clots, but aspirin is more preventive. Monitoring for arrhythmias is important but not the initial intervention. Administering morphine can be considered for pain relief but is not as crucial as administering aspirin to prevent further clot formation.

Correct Answer: A

Rationale: The correct answer is A because it focuses on prioritizing the assessment by first addressing the immediate problem of shortness of breath. By examining only the body areas related to the current issue, the nurse can quickly gather essential information to manage the patient's respiratory distress effectively. Once the critical issue is stabilized, a complete assessment can be conducted to identify any underlying problems or potential complications. This approach ensures that the nurse addresses the most urgent needs first before proceeding to a comprehensive assessment. Choice B is incorrect because it suggests only examining body areas directly related to the hospitalization problem, which may overlook other critical issues contributing to the shortness of breath. Choice C is incorrect as shortness of breath is not a normal finding and should not be dismissed without further evaluation. Choice D is incorrect as examining the entire body without focusing on the immediate issue may delay appropriate interventions for the patient's respiratory distress.