Which of the following signs and symptoms is indicative of a post-operative wound infection?

Correct Answer: B

Rationale: The correct answer is B: Tenderness, warmth, and swelling at the site. Post-operative wound infection often presents with localized tenderness, warmth, and swelling due to inflammation and immune response. Redness, heat, and purulent drainage (choice A) can also indicate infection but are not specific to wound infections. Excessive swelling and redness (choice C) may be present in inflammatory responses but do not specifically point to an infection. Fever, chills, and nausea (choice D) can be systemic signs of infection but are not specific to wound infections. Tenderness, warmth, and swelling are more indicative of a localized wound infection.

Correct Answer: D

Rationale: The correct answer is D: Administer morphine. Administering morphine is the first intervention for a client experiencing a myocardial infarction (MI) to help relieve pain and reduce anxiety. Oxygen may not be necessary if the client is not hypoxic. Administering aspirin is important but usually follows morphine. Monitoring ECG is crucial, but not the first intervention to address the immediate symptoms of MI.

Correct Answer: B

Rationale: The correct answer is B: Vitamin B12. Strict vegetarians, especially those who exclude all animal products, are at risk of Vitamin B12 deficiency as it is primarily found in animal products. Vitamin C (A) deficiency is more common in those with poor fruit and vegetable intake. Vitamin E (C) deficiency is rare and usually seen in individuals with specific medical conditions. Magnesium (D) deficiency can occur in individuals with poor dietary intake or certain medical conditions, but it is not the primary concern for strict vegetarians.

Correct Answer: B

Rationale: The given ABG values fall within normal ranges, indicating homeostasis. The pH is within the normal range (7.35-7.45), indicating acid-base balance. The PO2 is slightly lower but still within the normal range (80-100 mmHg). PCO2 falls within the normal range (35-45 mmHg), showing effective ventilation. The HCO3 level is also within the normal range (22-26 mEq/L), indicating proper kidney function. Therefore, all values are within normal limits, reflecting a state of homeostasis. Other choices are incorrect as they suggest imbalances in acid-base status, which is not seen with these values.

Correct Answer: A

Rationale: The correct answer is A: Administer pain relief. This is the priority action because managing pain is crucial in providing comfort and reducing distress for the client with a severe burn. Pain relief helps in improving the client's overall well-being and promotes better recovery. Administering corticosteroids (Choice B) is not the priority as pain relief takes precedence. Monitoring for infection (Choice C) is important but not the immediate priority. Applying dressings (Choice D) is also important but should come after administering pain relief.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. During an acute asthma attack, the priority intervention is to immediately open the airways to improve breathing. Bronchodilators, such as albuterol, work rapidly to dilate the bronchioles and relieve bronchospasms, making it the most effective initial treatment. Corticosteroids (B) are used for long-term control, not immediate relief. Applying oxygen and administering albuterol (C) is close, but bronchodilators should be given first for quicker relief. Applying a cold compress (D) is not appropriate for managing an asthma attack.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for an allergic reaction as it helps to reverse severe symptoms like swelling, difficulty breathing, and low blood pressure. Administering epinephrine promptly can prevent the allergic reaction from escalating into a life-threatening situation. Antihistamines (choice B) may be given after epinephrine for symptom relief but are not as immediate in action. Monitoring vital signs (choice C) is important, but administering epinephrine takes precedence in managing the allergic reaction. Providing a cold compress (choice D) may help with local swelling but does not address the systemic effects of the allergic reaction.

Correct Answer: D

Rationale: The correct answer is D (Morton's neuroma) because interventions for difficulty walking due to a foot mass include recommending proper footwear, orthotic devices, corticosteroid injections, physical therapy, and in severe cases, surgical removal of the mass. Morton's neuroma causes pain and tingling in the ball of the foot, leading to difficulty walking. Plantar fasciitis (A), Hallux valgus (B), and Hammertoe (C) do not typically present with a mass in the foot causing difficulty walking.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. This is the most important intervention for a client with an obstructed airway because it helps to ensure that the patient is receiving adequate oxygen supply to prevent hypoxia. Oxygen therapy can help maintain oxygen saturation levels and support proper gas exchange in the lungs. Monitoring respiratory rate (B) is important but not as critical as ensuring oxygen supply. Administering morphine (C) is contraindicated as it can depress respiratory function further. Administering fluids (D) is not the priority in managing an obstructed airway.