What should the nurse prioritize for a client who is at risk for developing a blood clot after surgery?

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: B

Rationale: Step 1: Administering IV antibiotics is important for treating infections, but in this case, the focus is on addressing the pain associated with the deep wound infection. Step 2: Administering pain relief helps improve the client's comfort and quality of life while the infection is being treated. Step 3: Changing the dressing is essential for wound care but does not directly address the client's pain from the infection. Step 4: Performing a CT scan may be necessary to assess the extent of the infection, but it does not directly provide immediate relief for the client's pain. Summary: Administering pain relief is the most appropriate intervention as it directly addresses the client's symptoms and improves their comfort level during the treatment of the deep wound infection.

Correct Answer: C

Rationale: The correct answer is C: Administer aspirin. Aspirin should be administered first to prevent further clot formation and reduce the risk of recurrent stroke. Monitoring blood pressure (A) is important but not the first priority. Administering IV fluids (B) is not necessary unless indicated. Applying a warm compress (D) is not a priority in the acute management of a stroke. Administering aspirin promptly can significantly impact the client's outcome by preventing further clot formation.

Correct Answer: C

Rationale: The correct answer is C: Monitor for transfusion reactions. When a client receiving a blood transfusion develops chills, it may indicate a transfusion reaction, such as a febrile non-hemolytic reaction. The nurse's first priority is to monitor the client closely for other signs of a reaction, such as fever, rash, or shortness of breath. Stopping the transfusion may be necessary, but monitoring for reactions is crucial to identify and manage any adverse effects promptly. Vital signs should be monitored as part of assessing for reactions. Performing a lumbar puncture is not indicated in this situation and is unrelated to managing a transfusion reaction.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. The first priority in caring for a client experiencing a stroke is to ensure adequate oxygen supply to the brain, as lack of oxygen can lead to further brain damage. Administering oxygen helps improve oxygenation and can prevent complications. Administering morphine (B) is not recommended as it can mask symptoms and delay diagnosis. Administering IV fluids (C) may be necessary but is not the first priority. Administering fibrinolytics (D) is a time-sensitive intervention for ischemic stroke but should be done after proper evaluation and confirmation of the type of stroke.