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A 56-year-old patient comes to the walk-in clinic for scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history for colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis?
- A. Diarrhea/Constipation related to altered bowel patterns.
- B. Knowledge Deficit related to disease process and diagnostic procedure.
- C. Risk for Fluid Volume Deficit related to rectal bleeding and diarrhea.
- D. Anxiety related to unknown outcomes and perceived threats to body integrity.
Correct Answer: D
Rationale: The patient's anger and threat to leave indicate significant anxiety, which must be addressed before proceeding with education or further assessment.
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For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)?
- A. Impaired skin integrity related to incision
- B. Impaired mobility related to decreased muscle strength
- C. Risk for aspiration related to decreased muscle strength
- D. Ineffective airway clearance related to decreased respiratory excursion
Correct Answer: D
Rationale: Ambulation addresses multiple postoperative issues, including mobility, respiratory function, constipation, and thromboembolism prevention.
A client is being treated for inhalational anthrax following bioterrorism exposure. Which of the following medications should NOT be expected as a common treatment for anthrax?
- A. Ciprofloxacin
- B. Doxycycline
- C. Amoxicillin
- D. Penicillin G
Correct Answer: D
Rationale: The correct answer is D, Penicillin G. Anthrax is caused by Bacillus anthracis, which is susceptible to ciprofloxacin and doxycycline. Penicillin and amoxicillin are not recommended due to the potential for B. anthracis to produce beta-lactamase, which can make the bacteria resistant to penicillin-based medications. Penicillin G is not effective in treating anthrax and should not be expected as a common treatment option.
What does progression of patients through various phases of care in a postanesthesia care unit (PACU) primarily depend on?
- A. Condition of patient
- B. Type of anesthesia used
- C. Preference of surgeon
- D. Type of surgical procedure
Correct Answer: A
Rationale: Patient condition dictates the progression through PACU phases, ensuring appropriate care levels.
What should a nurse include in the teaching plan for clients who have a potential for hypovolemia?
- A. Avoid alcohol and caffeine
- B. Increase intake of dried peas and beans
- C. Increase intake of milk and dairy products
- D. Avoid table salt or food containing sodium
Correct Answer: A
Rationale: Alcohol and caffeine are diuretics, increasing fluid loss and worsening hypovolemi Avoiding them helps maintain fluid balance.
While recovering from the anesthetic, what is the best position for Mrs. West?
- A. Supine with legs fully extended
- B. Prone with head turned to the side
- C. Lateral Sims with legs flexed
- D. Trendelenburg with head to the side
Correct Answer: D
Rationale: The correct answer is D: Trendelenburg with head to the side. This position helps prevent aspiration by promoting drainage of secretions from the mouth and reducing the risk of airway obstruction. Placing the patient in Trendelenburg position with the head to the side also helps facilitate proper blood flow and ventilation. Supine with legs fully extended (A) may increase the risk of airway obstruction and aspiration. Prone with head turned to the side (B) may obstruct the airway and hinder breathing. Lateral Sims with legs flexed (C) is not suitable for a patient recovering from anesthesia as it may not provide optimal airway clearance and respiratory support.