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A nurse is planning the postoperative care of a patient who is scheduled for radical prostatectomy. What intraoperative position will place the patient at particular risk for the development of deep vein thrombosis postoperatively?
- A. Fowlers position
- B. Prone position
- C. Supine position
- D. Lithotomy position
Correct Answer: D
Rationale: The correct answer is D: Lithotomy position. In lithotomy position, the patient's legs are elevated and positioned higher than the heart, which can lead to venous stasis and increase the risk of deep vein thrombosis (DVT). This position compresses the femoral veins, hindering blood flow and predisposing the patient to DVT formation.
Summary:
A: Fowlers position - Not typically associated with increased DVT risk.
B: Prone position - Not typically associated with increased DVT risk.
C: Supine position - Generally considered a safe position regarding DVT risk.
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When planning discharge teaching with a patient who has undergone a total mastectomy with axillary dissection, the nurse knows to instruct the patient that she should report what sign or symptom to the physician immediately?
- A. Fatigue
- B. Temperature greater than 98.5F
- C. Sudden cessation of output from the drainage device
- D. Gradual decline in output from the drain
Correct Answer: C
Rationale: The correct answer is C: Sudden cessation of output from the drainage device. This is crucial because it can indicate a potential complication like a blocked drain or infection, requiring immediate medical attention to prevent further issues. Other choices like fatigue (A) are common after surgery but not urgent. Temperature elevation (B) may indicate infection but is not as critical as sudden cessation of drainage. Gradual decline in output (D) is expected as the drainage decreases over time, so it doesn't require immediate reporting.
A nurse is aware of the need to assess patients risks for anaphylaxis. What health care procedure constitutes the highest risk for anaphylaxis?
- A. Administration of the measles-mumps-rubella (MMR) vaccine
- B. Rapid administration of intravenous fluids
- C. Computed tomography with contrast solution
- D. Administration of nebulized bronchodilators
Correct Answer: C
Rationale: The correct answer is C: Computed tomography with contrast solution. This procedure involves the use of contrast agents that can trigger anaphylaxis due to the patient's allergic reaction to the contrast solution. Contrast solutions contain substances like iodine, which can cause severe allergic reactions in some individuals. Anaphylaxis is a life-threatening allergic reaction that can occur rapidly and requires immediate intervention. Assessing the risk for anaphylaxis during this procedure is crucial to prevent any potential harm to the patient.
Incorrect choices:
A: Administration of the measles-mumps-rubella (MMR) vaccine - While allergic reactions can occur with vaccines, the risk of anaphylaxis with MMR vaccine is lower compared to the contrast solution used in CT scans.
B: Rapid administration of intravenous fluids - Rapid IV fluid administration can cause fluid overload or electrolyte imbalances, but it is not typically associated with triggering anaphylaxis.
D: Administration of nebulized bronchodil
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?
- A. From the tip of the nose to the earlobe
- B. From the tip of the earlobe to the xiphoid process
- C. From the tip of the earlobe to the nose to the xiphoid process
- D. From the tip of the nose to the earlobe to the xiphoid process
Correct Answer: C
Rationale: Rationale for Correct Answer (C): To determine the correct length of the nasogastric tube needed to be inserted, the nurse should measure from the tip of the earlobe to the nose and then to the xiphoid process. This method ensures that the tube reaches the stomach without coiling in the esophagus or being inserted too far down. The distance from the earlobe to the nose approximates the distance from the nose to the stomach, and measuring to the xiphoid process ensures proper placement. This technique minimizes the risk of complications such as aspiration or misplacement.
Summary of Incorrect Choices:
A: Measuring from the tip of the nose to the earlobe is incorrect because it does not take into account the distance to the stomach.
B: Measuring from the tip of the earlobe to the xiphoid process alone is incorrect because it does not consider the distance through the nasal passage.
D: Measuring from the tip of the nose to the earlobe to
A woman calls the clinic and tells the nurse she has had bloody drainage from her right nipple. The nurse makes an appointment for this patient, expecting the physician or practitioner to order what diagnostic test on this patient?
- A. Breast ultrasound
- B. Radiography
- C. Positron emission testing (PET)
- D. Galactography Chapter 59: Male Reproductive: Terminologies PLISSIT Model, Prostate Cancer, Testicular cancer, BPH & Erectile dysfunction (ED)
Correct Answer: A
Rationale: The correct answer is A: Breast ultrasound. Bloody drainage from the nipple can be indicative of various conditions such as breast cancer. A breast ultrasound is a non-invasive imaging test that can help visualize any abnormalities in the breast tissue, including masses or tumors. It is commonly used to evaluate breast symptoms like nipple discharge. Radiography (B) is not typically used for evaluating breast conditions. Positron emission testing (PET) (C) is more commonly used in cancer staging and may not be the first-line test for this symptom. Galactography (D) is a specific imaging test used to evaluate the ducts of the breast and may not be the initial test for bloody nipple discharge.
The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury?
- A. Avoid watching television or using a computer for more than 1 hour at a time.
- B. Use OTC antibiotic eye drops for at least 14 days.
- C. Avoid rubbing the eye on the affected side of the face.
- D. Rinse the eye on the affected side with normal saline daily for 1 week.
Correct Answer: C
Rationale: Step 1: Trigeminal neuralgia involves severe facial pain, often triggered by touch or movement.
Step 2: Rubbing the eye on the affected side can trigger pain due to the trigeminal nerve involvement.
Step 3: Therefore, advising the patient to avoid rubbing the eye on the affected side is crucial to prevent pain exacerbation and potential injury.
Step 4: Choices A, B, and D are incorrect as they do not directly address the risk of injury related to trigeminal neuralgia.