Nokea
A female postoperative client has returned to the Unit following a pneumonectomy. In assessing the client's incision, twenty-four hours postoperatively, the nurse notices fresh blood on the dressing. The nurse should first:
- A. reinforce the dressing.
- B. continue to monitor the dressing.
- C. notify the physician.
- D. note the time and amount of blood.
Correct Answer: C
Rationale: The dressing should not be reinforced without notifying the physician. The physician may decide to reinforce the dressing after assessing the amount of bleeding. Blood on the dressing is unusual, which should alert the nurse to do more than monitor the dressing. The physician should be notified immediately. If the bleeding persists, the client may need to return to surgery. The time and amount of blood needs to be recorded, but only after the physician is notified.
You may also like to solve these questions
The main goal of treatment for acute glomerulonephritis is to
- A. encourage activity.
- B. encourage high protein intake.
- C. maintain fluid balance.
- D. teach intermittent urinary catheterization.
Correct Answer: C
Rationale: Maintaining fluid balance is critical in managing acute glomerulonephritis due to potential fluid overload.
For a patient with osteogenic sarcoma, you would be particularly vigilant for elevations in which laboratory value?
- A. Sodium.
- B. Calcium.
- C. Potassium.
- D. Hematocrit.
Correct Answer: B
Rationale: Elevated calcium levels are commonly associated with osteogenic sarcoma due to bone destruction and release of calcium into the bloodstream.
While caring for an unconscious patient, the nurse discovers a stage 2 pressure ulcer on the patient’s heel. During care of the ulcer, what is the nurse’s understanding of the patient’s perception of pain?
- A. The patient will have a behavioral response if pain is perceived.
- B. The area should be treated as a painful lesion, using gentle cleansing and dressing.
- C. The area can be thoroughly scrubbed because the patient is not able to perceive pain.
- D. All nociceptive stimuli that are transmitted to the brain result in the perception of pain.
Correct Answer: B
Rationale: The correct answer is B. Even in unconscious patients, the area should be treated gently to avoid exacerbating potential pain.
A 35-year-old client is admitted for elective tubal ligation. During the preoperative teaching, the client states, 'The anesthesiologist said she was going to give me balanced anesthesia. What exactly is that?' The best explanation by the nurse is that balanced anesthesia:
- A. is a type of regional anesthesia.
- B. uses equal amounts of inhalation agents and liquid agents.
- C. does not depress the central nervous system.
- D. is a combination of several anesthetic agents or drugs, which produce a smooth induction with minimal complications.
Correct Answer: D
Rationale: A regional anesthesia does not produce loss of consciousness and is indicated for excision of moles, cysts, and endoscopic surgeries. Varying amounts of anesthetic agents are used when employing balanced anesthesia. The amounts used depend on the age, weight, condition of the client and the surgical procedure. General anesthesia is a drug induced depression of the central nervous system, which produces loss of consciousness and decreased muscle activity. Balanced anesthesia is a combination of a number of anesthetic agents that produce a smooth induction, appropriate depth of anesthesia, and appropriate muscle relaxation with minimal complications.
For care of a patient who has oral cancer, which task would be appropriate to delegate to the LPN/LVN?
- A. Assist the patient to brush and floss.
- B. Give antacids and sucralfate suspension as ordered.
- C. Recommend saliva substitutes.
- D. Explain when brushing and flossing are contraindicated.
Correct Answer: A
Rationale: Assisting with oral hygiene is within the scope of practice for LPNs/LVNs, while medication administration and patient education require higher-level training.