Nokea
While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurses most appropriate action?
- A. Page the physician and report this sign of infection.
- B. Reinforce the dressing and reassess in 1 to 2 hours.
- C. Reposition the patient to prevent further hemorrhage.
- D. Inform the surgeon of the possibility of a dural leak.
Correct Answer: B
Rationale: The most appropriate action for the nurse to take when observing the surgical dressing saturated with serosanguineous drainage is to reinforce the dressing and reassess in 1 to 2 hours. Serosanguineous discharge is a common type of drainage following surgery, as it is a mixture of blood and serum. It is expected in the early stages of wound healing and does not necessarily indicate infection. By reinforcing the dressing and closely monitoring the drainage over the next couple of hours, the nurse can assess if the amount of drainage is decreasing or escalating. If there are any signs of infection, such as increasing redness, warmth, swelling, or excessive purulent discharge, then the nurse should notify the physician promptly. Until then, it is appropriate to continue observing and managing the drainage within the expected range.
You may also like to solve these questions
An uncircumcised 78-year-old male has presented at the clinic complaining that he cannot retract his foreskin over his glans. On examination, it is noted that the foreskin is very constricted. The nurse should recognize the presence of what health problem?
- A. Bowens disease
- B. Peyronies disease
- C. Phimosis
- D. Priapism
Correct Answer: C
Rationale: Phimosis is a condition in which the foreskin of the penis is tight and cannot be retracted over the glans. It can occur in uncircumcised males, like the 78-year-old male in this scenario. Phimosis may lead to difficulty with hygiene, pain during sexual activity, and an increased risk of infections. Treatment may involve conservative measures such as topical corticosteroids or, in severe cases, surgical intervention like circumcision to alleviate the tightness of the foreskin.
A nurse is assessing population groups for therisk of suicide requiring medical attention. Which group should the nurse monitormostclosely?
- A. Young bisexuals
- B. Young caucasians
- C. Asian Americans
- D. African-Americans.
Correct Answer: A
Rationale: Gay, lesbian, and bisexual young people have a significantly increased risk for depression, anxiety, suicide attempts, and substance use disorders. In particular, bisexual youth are at a higher risk than their straight peers for experiencing mental health issues and suicide attempts that require medical attention. Studies have shown that young bisexuals are four times more likely than their straight counterparts to make suicide attempts that necessitate medical intervention. Therefore, it is crucial for the nurse to closely monitor this population group for signs of suicidal behavior and provide the necessary support and interventions to prevent such tragedies.
A nurse needs to begin discharge planning fora patient admitted with pneumonia and a congested cough. When is the besttime the nurse should start discharge planningfor this patient?
- A. Upon admission
- B. Right before discharge
- C. After the congestion is treated
- D. When the primary care provider writes the order
Correct Answer: A
Rationale: The best time for a nurse to start discharge planning for a patient admitted with pneumonia and a congested cough is upon admission. Starting discharge planning early allows the healthcare team to identify the patient's needs, plan for the appropriate level of care, and ensure a smooth transition out of the hospital. Waiting until right before discharge or after the congestion is treated may lead to rushed or incomplete planning, potentially compromising the patient's recovery and post-discharge care. Additionally, discharge planning is not dependent on the primary care provider writing an order, as nurses can initiate teaching and planning proactively to support the patient's optimal recovery and transition. By beginning discharge planning upon admission, the healthcare team can address any potential barriers to discharge and ensure the patient's needs are met for a successful recovery process.
You are caring for a patient who has just been told that his illness is progressing and nothing more can be done for him. After the physician leaves, the patient asks you to stay with him for a while. The patient becomes tearful and tries several times to say something, but cannot get the words out. What would be an appropriate response for you to make at this time?
- A. Can I give you some advice?
- B. Do you need more time to think about this?
- C. Is there anything you want to say?
- D. I have cared for lots of patients in your position. It will get easier.
Correct Answer: C
Rationale: This response shows empathy and allows the patient to express their thoughts and feelings without feeling rushed or pressured. By asking the patient if there is anything they want to say, you are showing that you are there to listen and support them during this difficult time. It is important to give the patient the space and opportunity to communicate their emotions and concerns. Offering advice or making assumptions about the patient's feelings may not be as helpful as simply providing a listening ear.
A middle-aged female patient has been offered testing for HIV/AIDS upon admission to the hospital for an unrelated health problem. The nurse observes that the patient is visibly surprised and embarrassed by this offer. How should the nurse best respond?
- A. Most women with HIV dont know they have the disease. If you have it, its important we catch it early.
- B. This testing is offered to every adolescent and adult regardless of their lifestyle, appearance or history.
- C. The rationale for this testing is so that you can begin treatment as soon as testing comes back, if its positive.
- D. Youre being offered this testing because you are actually in the prime demographic for HIV infection.
Correct Answer: B
Rationale: Option B is the best response for the nurse to provide in this situation. By stating that the testing is offered to every adolescent and adult regardless of lifestyle, appearance, or history, the nurse conveys that HIV testing is a standard practice and not targeting the patient specifically. This can help reduce the patient's feeling of embarrassment or stigma associated with the offer of testing. It also emphasizes the importance of universal screening for HIV to promote early detection and treatment, regardless of risk factors or demographics. This response helps maintain the patient's dignity and encourages them to consider the testing in a non-judgmental way.