Nokea
A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. What intervention should the nurse implement next?
- A. Bring additional sterile dressing supplies to the room
- B. Prepare the client to return to the operating room
- C. Obtain a sample of the drainage to send to the lab
- D. Auscultate the abdomen for bowel sound activity
Correct Answer: B
Rationale: Evisceration is a surgical emergency and requires immediate return to the operating room for repair.
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Recognised features of myotonic dystrophy include:
- A. Phenomenon of anticipation
- B. Muscle pain
- C. Diplopia
- D. Cardiomyopathy
Correct Answer: A
Rationale: The phenomenon of anticipation, where symptoms become more severe or appear at an earlier age as the disorder is passed through generations, is a recognized feature of myotonic dystrophy.
A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation?
- A. Low-sodium soups.
- B. Over all fluid intake
- C. Tea and hot chocolate
- D. Citrus fruit juices
Correct Answer: C
Rationale: Tea and hot chocolate contain oxalates, which can contribute to the formation of calcium oxalate stones. Limiting these fluids helps prevent recurrence.
Concerning SLE:
- A. Antibodies against double standard RNA are a typical finding
- B. Haematoxylin bodies occur in areas of inflammation
- C. Usually progresses to renal failure within two years
- D. Alopecia is a recognised finding
Correct Answer: D
Rationale: Alopecia is a recognized clinical feature of systemic lupus erythematosus (SLE), often associated with disease activity.
What is the age-predicted maximum heart rate in a 60-year old man on beta blockers?
- A. 122
- B. 133
- C. 155
- D. 166
Correct Answer: A
Rationale: Beta blockers reduce the maximum heart rate. The age-predicted maximum heart rate for a 60-year-old on beta blockers is approximately 122 bpm.
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?
- A. This is a routine surgery and the risk of death is very low.
- B. Would you like to speak with a chaplain before surgery?
- C. Tell me more about your concerns about the surgery.
- D. What support systems do you have to assist you?
Correct Answer: C
Rationale: Encouraging the client to express their concerns allows the nurse to provide emotional support and address specific fears.