Nokea
A nurse is assessing a surgical patient for internal hemorrhage. Which of the following would indicate internal hemorrhage?
- A. Headache.
- B. Rising pulse and falling blood pressure.
- C. Lethargy, falling pulse, and rising blood pressure.
- D. Restlessness, rising pulse, and falling blood pressure.
Correct Answer: D
Rationale: Restlessness, rising pulse, and falling blood pressure indicate hypovolemic shock from internal hemorrhage due to blood loss affecting circulation.
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When applying an ice pack, it is necessary to:
- A. Fill the pack and refreeze it.
- B. Cover the pack with plastic wrap.
- C. Use a light cover over the pack.
- D. use small ice cubes
Correct Answer: C
Rationale: A light cover prevents direct skin contact, reducing frostbite risk while allowing cold therapy.
What safety factors should be considered when using an Aquathermia pad unit for a patient? (Select all that apply)
- A. Inspecting the plug and cord for cracks or fraying
- B. Securing the pad to the patient
- C. Instructing the patient not to sleep on the pad
- D. Assisting the patient to lie on top of the pad
- E. Using a thermometer to check the temperature of the pad
Correct Answer: A,C
Rationale: A: Ensures electrical safety. C: Prevents burns from prolonged pressure. Lying on the pad (D) increases burn risk.
While assessing the client's abdomen, you note that the Jackson-Pratt drain's reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time?
- A. Empty the reservoir.
- B. Notify the surgeon about the drainage.
- C. Remove the drain
- D. Leave it until the end of the shift
Correct Answer: A
Rationale: Emptying the reservoir maintains drainage function and allows monitoring of output; significant changes would then prompt notifying the surgeon.
A nurse is ambulating a patient in the hall a few days after abdominal surgery when the patient says, "I think something just let go." What should be the nurse's initial intervention?
- A. Ask someone to quickly get an abdominal binder.
- B. Seat the patient in a nearby chair.
- C. Instruct the patient to pant to reduce abdominal tension.
- D. Assist the patient into a supine position.
Correct Answer: D
Rationale: Assisting to a supine position reduces strain on the abdominal wound, preventing further dehiscence.
The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:
- A. Excessive gas
- B. Complaint of constipation
- C. Increased drainage from the wound
- D. Increased pallor of the surgical site
Correct Answer: C
Rationale: Increased drainage suggests wound separation (dehiscence) as fluid escapes the incision.