Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. This is crucial for preventing blood clots post-surgery as they help thin the blood and reduce clot formation. Monitoring for arrhythmias (B) is important but not the priority in this case. While encouraging deep breathing (C) and fluid intake (D) are beneficial for post-surgical recovery, they do not directly address the risk of blood clot formation. Administering anticoagulants is the most effective intervention to prevent blood clots in high-risk surgical patients.

Correct Answer: A

Rationale: The correct answer is A: objective. Objective data refers to measurable and observable information obtained through physical examination or diagnostic tests. In this case, the nurse's documentation of the patient's respirations and pulse rate are objective data as they can be quantified and verified by any healthcare professional. This data is not influenced by personal feelings or interpretations, making it objective. Choice B, reflective, is incorrect as it does not describe the nature of the data provided. Choice C, subjective, is also incorrect because subjective data is based on the patient's feelings or perceptions, which is not the case here. Choice D, introspective, is incorrect as it refers to internal self-reflection, not the nature of the data being documented.

Correct Answer: B

Rationale: The correct answer is B: Hypertrophic scar. This type of scar is raised, red, and irregular, but it does not extend beyond the boundaries of the original wound like a keloid. A keloid is characterized by excessive scar tissue that grows beyond the wound site. Contracture is a scar that causes tightening of the skin and may restrict movement. Stretch marks, on the other hand, are not raised or irregular like the described scar.

Correct Answer: D

Rationale: Step 1: Establish rapport by showing interest in the patient's well-being. Step 2: Emphasize continuity of care by referencing the previous visit. Step 3: Encourage open communication about any changes or concerns. Step 4: Initiate discussion on the patient's health status since the last visit. Summary: A - Too broad and not focused on the patient's own health. B - Assumes the patient has a specific reason for the visit. C - Assumes the patient has hypertension and may not be relevant. D - Encourages discussion on the patient's health status and continuity of care.

Correct Answer: B

Rationale: The correct answer is B: Place the client in a supine position. This is the first step when administering Heparin to prevent bleeding or bruising at the injection site. Placing the client in a supine position helps reduce the risk of injury and promotes optimal absorption. Administering antipyretics (Choice A) is not the first step in administering Heparin. Administering insulin (Choice C) is unrelated to Heparin administration. Monitoring vital signs (Choice D) is important but typically done after the initial step of positioning the client correctly.