单项选择题

A male client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of severe pain in the surgical wound. Which action should the nurse take

A. Assume he’s anxious about discharge, and administer pain medication.
B. Assess the surgical site and affected extremity.
C. Reassure the client that pain is a direct result of increased activity.
D. Suspect a wound infection, and monitor the client’s temperature and vital signs.

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单项选择题From an analysis of the data collected about the client who has had a gastric resection, the nurse formulates the nursing diagnosis Risk for ineffective airway clearance. Based on which of the following postoperative factors would the nurse make this diagnosis

A. Incisional pain.
B. Nausea.
C. Progressive ambulation.
D. Maintenance of a semi-Fowler’s position.

单项选择题A client with heart failure loses 3.2 kg while hospitalized. Approximately how many pounds has the client lost

A. 1 pound.
B. 3 pounds.
C. 5 pounds.
D. 7 pounds.