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65-year-old Dominic is being transferred into the PACU from the OR. Once there, initial assessment will focus on:
- A. Airway, breathing, circulation, and wound site.
- B. Intake, output, and intravenous access.
- C. Abdominal sounds, oxygen setting, and level of consciousness.
- D. Pulse oximeter, pupil responses, and deep tendon reflexes.
Correct Answer: A
Rationale: The ABCs (airway, breathing, circulation) are the priority in postoperative assessments to ensure the patient's immediate physiological stability. The wound site is also assessed for signs of bleeding or infection.
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Why is it important for a nurse to move a victim of a common respiratory toxin to higher ground immediately?
- A. The toxins flow to the lower ground.
- B. The toxic vapors stay close to the ground.
- C. The toxins are always released close to the ground.
- D. The heavy and the solid toxins cannot move to a height.
Correct Answer: B
Rationale: The correct answer is B because many respiratory toxins are heavier than air and settle near the ground.
Symptoms of an ectopic pregnancy include:
- A. Hematuria, pelvic pain, and dizziness
- B. Amenorrhea, pelvic pain, and vaginal spotting
- C. Constipation, nausea, and fainting
- D. Fallopian pain, nausea, and breast enlargement
Correct Answer: B
Rationale: Ectopic pregnancies often present with amenorrhea, pelvic pain, and vaginal spotting due to the abnormal implantation site.
What would be useful in helping Mr. Jackson prepare for chest tube insertion?
- A. Explain the etiology of his condition
- B. Ask if he has any questions about the insertion procedure and its purpose
- C. Teach him to splint his chest wall
- D. Reassure him that the procedure is painless
Correct Answer: C
Rationale: Splinting minimizes movement and discomfort during the procedure.
The old-old population (85 years and older) has an increased risk for frailty. However, old age is just one element of frailty. Identify at least three other assessment findings that contribute to frailty.
- A. Decreased muscle mass
- B. Weight loss
- C. Reduced physical activity
- D. Increasing disability and symptoms
Correct Answer: A
Rationale: Decreased muscle mass, unintentional weight loss, and reduced physical activity are key contributors to frailty in older adults.
A patient who has been taking ibuprofen (Motrin) and imipramine (Tofranil) for control of cancer pain is having increased pain. What would the health care provider recommend as an appropriate change in the medication plan?
- A. Add PO oxycodone (Oxycontin) to the other medications
- B. Substitute PO propoxyphene (Darvon), a mild opioid, for imipramine
- C. Add transdermal fentanyl (Duragesic) to the use of the other medications
- D. Substitute PO hydrocodone with acetaminophen (Lortab, Vicodin) for the other medications
Correct Answer: C
Rationale: The correct answer is C. Adding a stronger opioid like transdermal fentanyl can address increased pain.