Nokea
An oncology patient has just returned from the postanesthesia care unit after an open hemicolectomy. This patient's plan of nursing care should prioritize which of the following?
- A. Assess the patient hourly for signs of compartment syndrome
- B. Assess the patient's fine motor skills once per shift
- C. Assess the patient's wound for dehiscence every 4 hours
- D. Maintain the patient's head of bed at 45 degrees or more at all times
Correct Answer: C
Rationale: Post-hemicolectomy, wound dehiscence splitting open is a killer risk, tied to infection or poor healing, needing checks every 4 hours. Compartment syndrome's a fracture thing, not gut surgery. Fine motor's irrelevant here neuro's not the issue. High head-of-bed helps breathing but isn't universal post-op. Nurses in oncology prioritize this, catching leaks or redness early, critical after cancer gut surgery.
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Which is the most common organism infecting coral cuts?
- A. non-cholera vibrio
- B. mycobacterium marinum
- C. aeromonas species
- D. strep pyogenes
Correct Answer: D
Rationale: Coral cuts strep pyogenes streaks in, not vibrio, mycobacterium, aeromonas, or E. coli's swim. Nurses hit this chronic skin ripper.
Characteristics of acute pain do not include:
- A. Recent onset
- B. Attributable to specific injury or disease
- C. Lasts from a few minutes to less than 6 months
- D. Unable to be relieved by analgesia
Correct Answer: D
Rationale: Acute pain fresh, tied to harm, short-lived yields to pills, not stubborn. Nurses spot this, a chronic pain foil.
A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?
- A. Helping clients adjust to their appearance
- B. Reassuring clients that this change is temporary
- C. Referring clients to a reputable wig shop
- D. Teaching measures to prevent scalp injury
Correct Answer: D
Rationale: Alopecia, or hair loss, is a common chemotherapy side effect due to drugs targeting rapidly dividing cells, including hair follicles. While emotional support is vital, the priority is client safety. Teaching measures to prevent scalp injury such as avoiding harsh brushing or sun exposure takes precedence because the scalp becomes vulnerable without hair's protective barrier, risking cuts, infections, or burns. Helping clients adjust to appearance and reassuring them about regrowth address psychosocial needs but don't mitigate physical risk. Referring to a wig shop is practical but secondary to safety. In oncology nursing, prioritizing physical protection aligns with the hierarchy of needs, ensuring the client avoids complications like infection, especially if immunocompromised, before addressing emotional impacts.
The nurse is assessing a client with severe anemia. Which clinical manifestation does the nurse expect to see in this client?
- A. Bradycardia
- B. Pale, cool skin
- C. Hypertension
- D. Warm, flushed skin
Correct Answer: B
Rationale: Severe anemia starves oxygen pale, cool skin reflects shunted flow and low hemoglobin, a classic find as body compensates. Bradycardia's rare; tachycardia revs to pump more. Hypertension doesn't fit BP may drop. Warm, flushed skin suits overload, not anemia. Nurses expect pallor, tying it to blood's oxygen flop, a sign guiding transfusion or iron.
A 63 years old woman who is known to have hypertension for 15 years presented to her family doctor with shortness of breath and ankle swelling. An echocardiogram confirmed compromised left ventricular function. Her blood pressure is 150/90 mmHg. She is currently on frusemide and Aspirin. What is the MOST appropriate medication to add?
- A. Aldosterone antagonists
- B. Calcium channel blockers
- C. Beta blockers
- D. Angiotensin converting enzyme - inhibitors
Correct Answer: D
Rationale: Heart failure with LV dysfunction ACE inhibitors cut mortality, ease load, atop frusemide's fluid flush and aspirin's clot block. Aldosterone blockers add later; calcium blockers don't help heart; beta blockers need stability first; ARBs sub if ACE flops. Nurses push this chronic heart saver, proven to stretch life.