A postoperative patient complains of pain at the surgical site incision. Which of the following would be the priority action for the nurse to take?

Observe the cardiac monitor for increased heart rate

Ask the patient to rate the level of pain

Assess the patient’s body language

Inspect the incision site

Answer and Explanation

The Correct Answer is B

Choice A reason: Observing the cardiac monitor for increased heart rate may indicate pain indirectly, but it is not the priority. Heart rate changes can result from various factors (e.g., anxiety, hypovolemia). Directly assessing the patient’s pain level provides specific, subjective data to guide interventions, making this choice less immediate.

Choice B reason: Asking the patient to rate the level of pain is the priority, as it directly quantifies the patient’s subjective experience using a standardized scale (e.g., 0-10). This guides pain management decisions, ensures timely intervention, and aligns with patient-centered care, making it the most critical initial action.

Choice C reason: Assessing body language can provide nonverbal pain cues, but it is less precise than verbal pain rating. Subjective pain assessment via patient report is the gold standard, as body language may be misinterpreted or influenced by cultural factors, making this a secondary action.

Choice D reason: Inspecting the incision site is important to rule out complications (e.g., infection, dehiscence), but pain assessment takes precedence to address the patient’s immediate complaint. Pain rating informs whether inspection or other interventions are urgent, making this a follow-up rather than priority action.

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Correct Answer is C

Explanation

Choice A reason: Consuming 30 g of fiber daily benefits digestion and glycemic control but is not specific to type 1 diabetes management. Blood glucose monitoring is critical, making this a secondary intervention.

Choice B reason: Oral hypoglycemics are used for type 2 diabetes, not type 1, which requires insulin due to absolute insulin deficiency. This is incorrect for type 1 diabetes management.

Choice C reason: Monitoring blood glucose four times daily is essential for type 1 diabetes to guide insulin dosing and prevent hypo- or hyperglycemia. This ensures tight glycemic control, making it the correct intervention.

Choice D reason: A bulk-forming laxative addresses constipation, not a primary concern in type 1 diabetes. Glucose monitoring directly manages the condition, making laxatives irrelevant to the care plan.

A. Low blood pressure B. Cancer C. Diabetes D. Alkalosis E. Infections

Correct Answer is ["C","E"]

Explanation

Choice A reason: Prolonged stress elevates cortisol, increasing blood pressure via vasoconstriction and sodium retention, not lowering it. Low blood pressure is not a typical stress-related condition, making this an incorrect choice for monitoring.

Choice B reason: Cancer risk may increase with chronic stress due to immune suppression, but it is not an immediate condition to monitor. Acute stress-related issues like diabetes or infections are more urgent, making this incorrect.

Choice C reason: Prolonged stress increases cortisol, promoting insulin resistance and hyperglycemia, raising diabetes risk. Monitoring blood glucose is critical, as stress exacerbates glycemic control, making this a correct condition to monitor.

Choice D reason: Alkalosis is not directly linked to prolonged stress, which more commonly causes metabolic acidosis in severe cases (e.g., lactic acidosis). Respiratory or metabolic alkalosis is less relevant, making this incorrect.

Choice E reason: Prolonged stress suppresses immunity via cortisol, increasing infection susceptibility. Monitoring for signs like fever or delayed healing is essential, as infections are a common stress complication, making this correct.

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A postoperative patient complains of pain at the surgical site incision. Which of the following would be the priority action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has type 1 diabetes mellitus. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is assessing a patient with prolonged stress. Which conditions will the nurse monitor for in this patient? (Select all that apply)

Correct Answer is ["C","E"]

Explanation

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