What is the most appropriate intervention for serosanguineous drainage after cholecystectomy?

Correct Answer: C

Rationale: Rationale: C: Reinforce the dressing is the correct intervention for serosanguineous drainage after cholecystectomy. This helps maintain a clean and dry wound environment, promotes healing, and prevents infection. Changing the dressing (B) may disrupt the wound healing process. Notifying the physician (A) is important but not the immediate intervention. Applying an abdominal binder (D) is not indicated for managing serosanguineous drainage.

Correct Answer: A

Rationale: The correct answer is A: Open the airway. This is the first action because in respiratory distress, ensuring a clear airway is crucial for adequate oxygenation. Opening the airway helps facilitate breathing and prevents further complications. Administering oxygen (choice B) can be done after ensuring the airway is clear. Administering medication (choice C) and pain relief (choice D) are not the initial priority in managing respiratory distress.

Correct Answer: D

Rationale: Correct Answer: D - Administering oxygen Rationale: 1. Oxygen is crucial in acute myocardial infarction to improve oxygenation and reduce myocardial workload. 2. Administering oxygen helps alleviate ischemia and prevents further damage. 3. Prioritizing oxygenation before pain medication or assessment ensures immediate intervention for the patient's well-being. Summary of other choices: A: Administering pain medication - Important for comfort but not the priority in acute myocardial infarction. B: Performing a head-to-toe assessment - Necessary but not as urgent as ensuring oxygenation. C: Establishing an intravenous line - Helpful but not as critical as administering oxygen in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Jaundice. In chronic liver disease, the liver's ability to process bilirubin is impaired, leading to jaundice. This is characterized by a yellowing of the skin and eyes. Monitoring for jaundice is crucial as it indicates liver dysfunction. Hypoglycemia (A) is not a typical complication of chronic liver disease. Hyperkalemia (B) is more commonly associated with kidney dysfunction. Anemia (D) can occur in liver disease but is not as specific a complication as jaundice. Therefore, monitoring for jaundice in a patient with chronic liver disease is essential for early detection and management of liver dysfunction.

Correct Answer: D

Rationale: The correct answer is D because understanding the mother's pregnancy history can provide crucial insights into potential risk factors or exposures that could have contributed to the child's pneumonia. By knowing about the mother's smoking or drug use during pregnancy, the healthcare team can better assess the child's overall health and potential underlying conditions. Choice A is incorrect as it dismisses the importance of the question and fails to address the potential significance of the information. Choice B is incorrect as it downplays the relevance of the question, which is essential for gathering comprehensive information for the child's care. Choice C is incorrect as it makes an unsupported and potentially misleading statement about the direct cause of pneumonia without considering other factors.

Correct Answer: B

Rationale: The correct answer is B: Administer pain relief. The first priority for a client with an open wound is to manage their pain to ensure their comfort and well-being. Pain relief helps the client relax, reduces stress, and promotes healing. Cleaning and dressing the wound, administering anticoagulants, and monitoring blood pressure are important tasks but are secondary to addressing the client's immediate pain and discomfort. Pain relief should be the initial focus to ensure the client's overall care and recovery.

Correct Answer: C

Rationale: Rationale: C: Reinforce the dressing is the correct intervention for serosanguineous drainage after cholecystectomy. This helps maintain a clean and dry wound environment, promotes healing, and prevents infection. Changing the dressing (B) may disrupt the wound healing process. Notifying the physician (A) is important but not the immediate intervention. Applying an abdominal binder (D) is not indicated for managing serosanguineous drainage.

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. This is the best nursing action for a client with a wound infection because antibiotics are necessary to treat the infection at its source, targeting the bacteria causing the infection. Antibiotics help prevent the infection from spreading and promote healing. Explanation of why other choices are incorrect: B: Applying a sterile dressing is important for wound care but does not address the underlying infection. C: Monitoring blood pressure is important for overall patient assessment but does not directly treat the wound infection. D: Placing the client in a sitting position is not relevant to treating a wound infection.

Correct Answer: D

Rationale: The correct answer is D: Encouraging early ambulation. Early ambulation helps prevent complications such as blood clots, pneumonia, and muscle weakness. It improves circulation, lung function, and overall recovery. Administering pain medication regularly (A) is important but not the top priority. Deep breathing exercises (B) are beneficial but not as crucial as early ambulation post-hip replacement. Monitoring for signs of infection (C) is essential but not the top priority for preventing complications in this case.