What should the nurse do when a client develops a fever after surgery?

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: C

Rationale: The correct answer is C: Assessing for signs of infection. This is the priority because diabetic foot ulcers are at high risk for infection, which can lead to serious complications. By assessing for signs of infection such as redness, warmth, swelling, pus, or foul odor, the nurse can promptly identify and initiate appropriate treatment. Administering antibiotics (A) should be based on the assessment findings. Providing pain relief (B) is important but not the priority when infection is a concern. Encouraging weight-bearing activity (D) may worsen the ulcer and should be avoided initially.

Correct Answer: A

Rationale: The correct answer is A: Light therapy. Light therapy is effective for treating sleep problems, stress, and seasonal affective disorders because exposure to bright light can regulate circadian rhythms, improve mood, and alleviate symptoms associated with these conditions. Light therapy helps reset the body's internal clock, promoting better sleep patterns and reducing stress. Exercise (choice B) can also improve sleep and reduce stress, but it may not specifically target seasonal affective disorders. Medication (choice C) and herbal treatments (choice D) are not typically recommended as the first-line treatment for these conditions and may have side effects or limited efficacy compared to light therapy.

Correct Answer: A

Rationale: Step-by-step rationale: 1. High HDL cholesterol is associated with decreased cardiovascular disease risk. 2. HDL cholesterol helps remove LDL cholesterol from arteries, reducing plaque buildup. 3. This leads to lower risk of heart disease and stroke. 4. Low HDL cholesterol (choice B) is associated with increased risk. 5. Low total cholesterol (choice C) and low triglycerides (choice D) do not directly correlate with decreased cardiovascular disease risk. Summary: High HDL cholesterol is beneficial for cardiovascular health as it helps reduce plaque buildup in arteries. Low HDL cholesterol, low total cholesterol, and low triglycerides are not associated with decreased cardiovascular disease risk.

Correct Answer: B

Rationale: The correct answer is B because the Set Test typically involves naming 10 items based on specific categories, such as those in the FACT acronym (Fruit, Animal, Color, and Town). The nurse should inform Mr. C. that he can complete the task without any hurry, which helps reduce stress and allows him to focus on recalling the items. This approach aligns with the standard administration procedure of the Set Test, promoting a relaxed and supportive environment for the patient. Choice A is incorrect because the nurse should not offer direct assistance or mention availability to help unless Mr. C. explicitly requests it. Choice C is incorrect as prompting the patient's memory may interfere with the natural cognitive process being assessed. Choice D is incorrect because imposing a time limit can induce unnecessary pressure and potentially affect the accuracy of the results.

Correct Answer: B

Rationale: The correct answer is B: Encourage fluid intake. Adequate hydration helps in pain management by promoting circulation and reducing inflammation. Opioids (choice A) should only be used if non-pharmacological interventions fail. Administering oxygen (choice C) is not typically indicated for pain management. Monitoring electrolyte levels (choice D) is important but not the most immediate intervention for acute pain post-surgery.

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: D

Rationale: The correct answer is D because it provides a thorough list of specific childhood illnesses and confirms the patient's denial of having had them. This approach ensures comprehensive documentation and accuracy. Choice A is vague and lacks specificity, potentially leading to misunderstandings. Choice B focuses on the patient's perception of their health rather than actual illnesses. Choice C mentions the patient's sister and measles, which is irrelevant to the patient's own medical history. Overall, choice D is the most accurate and relevant option for documenting the patient's childhood illnesses.

Correct Answer: A

Rationale: The correct answer is A - Administer IV fluids. This is the priority intervention for a client with suspected hypovolemia and hypotension as it helps to restore intravascular volume and improve blood pressure. IV fluids will address the underlying cause of hypotension by increasing circulating volume. Monitoring blood pressure (B) is important but administering IV fluids takes precedence. Administering corticosteroids (C) is not indicated for hypovolemia and hypotension. Administering oxygen (D) may be necessary if there is evidence of hypoxia, but addressing fluid volume status is the primary concern in this scenario.