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: A

Rationale: The correct answer is A: Administer antiepileptic drugs. This is the most important nursing action for a client with a history of seizures because antiepileptic drugs help prevent or reduce the frequency and severity of seizures. By ensuring the client receives their prescribed medication, the nurse can help manage the condition effectively. Placing the client on their side (B) is important to prevent aspiration if a seizure occurs, but administering antiepileptic drugs is more crucial for long-term management. Checking the airway (C) is important during and after a seizure but does not address the underlying cause. Monitoring for hypoglycemia (D) is important as a potential trigger for seizures, but administering antiepileptic drugs takes precedence in managing the condition.

Correct Answer: A

Rationale: The proper hand position for chest percussion is to cup the hands, creating a hollow space to allow for effective transmission of percussion vibrations. Cupping the hands helps to produce the desired percussion sound and ensures proper force distribution. Using the side of the hands (B) may not provide enough surface area for effective percussion. Flattening the hands (C) may not generate the desired percussive effect, and spreading the fingers of both hands (D) can result in uneven force application. Therefore, cupping the hands is the most appropriate hand position for chest percussion.

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: D

Rationale: The correct answer is D: Administer diuretics. The priority for a nurse caring for a client with pneumonia is to maintain adequate oxygenation and prevent respiratory failure. Diuretics help reduce fluid overload in the lungs, improving gas exchange and oxygenation. Administering antibiotics (choice A) is important to treat the infection but not the top priority. Administering oxygen (choice B) is crucial for oxygenation, but diuretics take precedence to improve lung function. Administering corticosteroids (choice C) may be considered in certain cases to reduce inflammation, but it is not the primary priority.

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 correct answer is B: Apply sterile dressings. This is the priority nursing intervention for a client with a deep wound infection because it helps prevent further contamination and promotes wound healing. Sterile dressings create a barrier against external pathogens and keep the wound environment clean, which is crucial in managing infections. Administering IV antibiotics (choice A) may be necessary but treating the wound first is essential. Applying heat to the wound (choice C) can worsen the infection by promoting bacterial growth. Administering IV fluids (choice D) may be needed for hydration but is not the priority in managing a deep wound infection.

Correct Answer: A

Rationale: The correct answer is A: coma. High ammonia levels can lead to hepatic encephalopathy, causing impaired brain function and potentially leading to coma. Edema (B) is typically associated with fluid retention, not high ammonia levels. Hypoxia (C) is a condition of low oxygen levels, not directly related to high ammonia levels. Polyuria (D) is excessive urination, which is not a common sign of high ammonia levels.

Correct Answer: A

Rationale: The correct answer is A: Assess airway. In caring for a client with a traumatic head injury, the first priority is to ensure there is a clear airway to maintain oxygenation and ventilation, which is crucial for brain function. If the airway is compromised, it can lead to hypoxia and further brain damage. Providing pain relief (B) is important but not the immediate priority. Monitoring intracranial pressure (C) is essential but comes after ensuring a patent airway. Maintaining a quiet environment (D) can help reduce stimulation, but it is not as critical as assessing the airway for immediate intervention.