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: 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: A

Rationale: The nurse should first administer aspirin to a client with chest pain as it helps prevent blood clot formation during a possible heart attack. Aspirin inhibits platelet aggregation, reducing the risk of further blockage in the coronary arteries. Administering aspirin promptly can improve the client's outcomes. Performing an ECG, monitoring vital signs, or providing a meal plan are important but should come after administering aspirin in the initial management of chest pain to prioritize the client's safety and well-being.

Correct Answer: A

Rationale: The correct answer is A: Monitor aPTT levels. This is crucial in intravenous heparin therapy to ensure the therapeutic range is maintained for anticoagulation without causing bleeding. Monitoring aPTT helps adjust heparin dosage to prevent clot formation or excessive bleeding. B: Monitoring for bleeding is important but not the most important action compared to monitoring aPTT levels for appropriate dosing. C: Checking platelet count is important for some anticoagulants like heparin, but aPTT monitoring is more directly related to heparin's anticoagulant effect. D: Administering a heparin antidote (protamine sulfate) is necessary in case of heparin overdose or in emergency situations but is not the primary action in routine care.

Correct Answer: A

Rationale: The correct answer is A: Assess vital signs. This is the first intervention because it provides immediate information on the client's condition and helps determine the severity of the pain. Monitoring vital signs can reveal signs of shock, dehydration, or other serious complications. Performing a CT scan (B) is not the first priority as it requires time and resources. Monitoring urine output (C) may be important but not as immediate as assessing vital signs. Monitoring for signs of shock (D) can be included in assessing vital signs but is not the primary intervention.

Correct Answer: B

Rationale: The correct answer is B: Place in a safe environment. This is the first priority to ensure the safety of the confused post-operative client. Placing the client in a safe environment prevents harm from falls or accidents. Reorienting the client (choice A) can come after ensuring safety. Administering pain relief (choices C and D) should be done based on assessment but is not the first priority when the client is confused.

Correct Answer: B

Rationale: Mammography is used to detect tumors in the breast tissue. It is a screening tool for breast cancer. Tumors can be either benign or malignant. Mammograms help in early detection of abnormalities in breast tissue. Pain, edema, and epilepsy are unrelated to the purpose of mammography. Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder. Therefore, the correct answer is B because mammography is specifically designed to detect tumors in the breast.

Correct Answer: D

Rationale: The correct answer is D because when a client experiences an allergic reaction to a medication, the nurse should monitor for signs of infection as allergic reactions can sometimes lead to secondary infections. By closely monitoring the client for signs of infection, the nurse can promptly intervene and provide appropriate treatment. A: Discontinuing the medication is important but not the immediate priority when dealing with an allergic reaction. B: Notifying the healthcare provider is important, but monitoring for signs of infection takes precedence in this situation. C: Administering antihistamines may help with allergic symptoms but does not address the potential risk of secondary infection.

Correct Answer: B

Rationale: The correct action for a client with DVT in the leg is to apply compression and elevate the leg (Choice B). Compression helps prevent blood clots from moving and causing further complications. Elevating the leg reduces swelling and improves blood flow. Choice A is incorrect because applying heat can actually worsen DVT by promoting inflammation and increasing blood flow. Choice C is incorrect as massage can dislodge blood clots and lead to serious complications like pulmonary embolism. Choice D is incorrect as massaging the leg can be dangerous in DVT as mentioned before.