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A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the patients preoperative teaching?
- A. The procedure is an effective, time-tested treatment for sensory hearing loss.
- B. The patient is likely to experience resolution of conductive hearing loss after the procedure.
- C. Several months of post-procedure rehabilitation will be needed to maximize benefits.
- D. The procedure is experimental, but early indications suggest great therapeutic benefits.
Correct Answer: B
Rationale: The correct answer is B: The patient is likely to experience resolution of conductive hearing loss after the procedure. This information is crucial to include in the preoperative teaching because it directly addresses the patient's expected outcome, providing reassurance and setting appropriate expectations. Stapedectomy with prosthesis insertion is a well-established treatment for otosclerosis-related conductive hearing loss. Choices A, C, and D are incorrect because they either provide misleading information (A, D) or are not directly relevant to the procedure or the patient's immediate postoperative experience (C). It is important to focus on accurate and relevant information to prepare the patient effectively for the upcoming surgery and its expected outcomes.
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A clinic nurse is providing preprocedure education for a man who will undergo a vasectomy. Which of the following measures will enhance healing and comfort? Select all that apply.
- A. Abstaining from sexual intercourse for at least 14 days postprocedure
- B. Wearing a scrotal support garment
- C. Using sitz baths
- D. Applying a heating pad intermittently E) Staying on bed rest for 48 to 72 hours postprocedure
Correct Answer: A
Rationale: The correct answer is A: Abstaining from sexual intercourse for at least 14 days postprocedure. This is important to allow the surgical site to heal properly and reduce the risk of complications. Choice B, wearing a scrotal support garment, can provide comfort but does not directly enhance healing. Choice C, using sitz baths, may help with discomfort but may not specifically promote healing. Choice D, applying a heating pad intermittently, could potentially increase the risk of infection. Choice E, staying on bed rest for 48 to 72 hours postprocedure, is unnecessary and could lead to complications such as blood clots.
An oncology patient has just returned from the postanesthesia care unit after an open hemicolectomy. This patients plan of nursing care should prioritize which of the following?
- A. Assess the patient hourly for signs of compartment syndrome.
- B. Assess the patients fine motor skills once per shift.
- C. Assess the patients wound for dehiscence every 4 hours.
- D. Maintain the patients head of bed at 45 degrees or more at all times.
Correct Answer: C
Rationale: The correct answer is C because assessing the patient's wound for dehiscence every 4 hours is crucial post hemicolectomy to monitor for any signs of wound complications, such as infection or tissue breakdown. This allows for early detection and intervention, promoting optimal wound healing and preventing potential complications.
Choice A is incorrect as compartment syndrome is not a common complication after a hemicolectomy, and assessing for it hourly would be excessive and unnecessary.
Choice B is incorrect as assessing fine motor skills is not a priority in the immediate postoperative period following a hemicolectomy.
Choice D is incorrect as maintaining the patient's head of bed at 45 degrees or more is important for preventing respiratory complications, but it is not the top priority compared to wound assessment for dehiscence in this scenario.
A child has been transported to the emergency department (ED) after a severe allergic reaction. The ED nurse is evaluating the patients respiratory status. How should the nurse evaluate the patients respiratory status? Select all that apply.
- A. Facilitate lung function testing.
- B. Assess breath sounds.
- C. Measure the childs oxygen saturation by oximeter.
- D. Monitor the childs respiratory pattern. E) Assess the childs respiratory rate.
Correct Answer: B
Rationale: Rationale: Assessing breath sounds is crucial in evaluating respiratory status as it helps identify any signs of airway obstruction or respiratory distress. This includes listening for wheezing, crackles, or diminished breath sounds. Lung function testing (A) may not be feasible in an acute emergency situation. Oxygen saturation (C) is important but does not provide a comprehensive assessment of respiratory status. Monitoring respiratory pattern (D) and assessing respiratory rate (E) are important but do not directly assess breath sounds, which are vital in identifying immediate respiratory issues.
A 42-year-old man has come to the clinic for an annual physical. The nurse notes in the patients history that his father was treated for breast cancer. What should the nurse provide to the patient before he leaves the clinic?
- A. A referral for a mammogram
- B. Instructions about breast self-examination (BSE)
- C. A referral to a surgeon
- D. A referral to a support group
Correct Answer: A
Rationale: The correct answer is A: A referral for a mammogram. Given the family history of breast cancer in the patient's father, the nurse should recommend a mammogram as a preventive measure due to increased risk. Mammograms are effective in detecting breast cancer early, especially in individuals with a family history. This can help in early diagnosis and timely intervention if needed.
B: Instructions about breast self-examination (BSE) can be helpful, but in this case, a mammogram is a more definitive screening tool for high-risk individuals.
C: A referral to a surgeon is not necessary at this point as the patient does not exhibit any symptoms of breast cancer.
D: Referral to a support group may be beneficial for emotional support, but the priority should be on proactive screening measures like a mammogram.
A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the
nurse expect?
- A. Distended abdomen
- B. Decreased skin turgor
- C. Increased energy levels
- D. Elevated blood pressure
Correct Answer: B
Rationale: The correct answer is B: Decreased skin turgor. Diarrhea leads to fluid loss, causing dehydration and decreased skin turgor. This indicates the patient's hydration status. A: Distended abdomen is more common in conditions like bowel obstruction, not necessarily in diarrhea. C: Increased energy levels are unlikely due to the patient's weakened state from dehydration. D: Elevated blood pressure is not typically associated with dehydration.