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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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A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patients health status?
- A. For some patients, these recurrent infections constitute an age-related physiologic change.
- B. The patient would benefit from a temporary mobility restriction to facilitate healing.
- C. The patient needs to be assessed for nasopharyngeal cancer.
- D. Blood cultures should be drawn to rule out a systemic infection.
Correct Answer: A
Rationale: Step 1: Serous otitis media is common in children due to eustachian tube dysfunction, not usually related to systemic infections.
Step 2: Recurrent infections may indicate age-related changes like decreased eustachian tube function.
Step 3: Age-related physiologic changes can lead to poor drainage, causing recurrent otitis media.
Step 4: Therefore, choice A is correct as it aligns with the typical presentation of serous otitis media in the context of age.
Summary: Choice B is incorrect as there is no indication for temporary mobility restriction. Choice C is incorrect as serous otitis media does not typically warrant assessment for nasopharyngeal cancer. Choice D is incorrect as blood cultures are not typically indicated for serous otitis media.
The nurse is describing some of the major characteristics of cancer to a patient who has recently received a diagnosis of malignant melanoma. When differentiating between benign and malignant cancer cells, the nurse should explain differences in which of the following aspects? Select all that apply.
- A. Rate of growth
- B. Ability to cause death
- C. Size of cells
- D. Cell contents E) Ability to spread
Correct Answer: A
Rationale: The correct answer is A: Rate of growth. Malignant cancer cells grow and divide rapidly compared to benign cells. Benign cells are usually slow-growing and have a well-defined border, while malignant cells grow uncontrollably and invade surrounding tissues. The other choices are incorrect because: B: Ability to cause death - Both benign and malignant cells have the potential to cause harm, but the key difference lies in their growth rate and invasiveness. C: Size of cells - The size of cells does not necessarily differentiate between benign and malignant cells. D: Cell contents - While malignant cells may have abnormal cell contents, this is not a defining characteristic when differentiating between benign and malignant cells. E: Ability to spread - While the ability to spread is a key characteristic of malignant cells, the primary differentiating factor in this question is the rate of growth.
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 caring for a teenage girl who has had an anaphylactic reaction after a bee sting. The nurse is providing patient teaching prior to the patients discharge. In the event of an anaphylactic reaction, the nurse informs the patient that she should self-administer epinephrine in what site?
- A. Forearm
- B. Thigh
- C. Deltoid muscle
- D. Abdomen
Correct Answer: B
Rationale: The correct answer is B: Thigh. When administering epinephrine during an anaphylactic reaction, the thigh is the recommended site due to its large muscle mass and quick absorption rate. Steps: 1. Remove safety cap. 2. Firmly push the auto-injector against the thigh until it clicks. 3. Hold in place for a few seconds. 4. Seek medical help immediately. Rationale for incorrect choices: A: Forearm - Not recommended due to smaller muscle mass and slower absorption. C: Deltoid muscle - Not preferred as it may not provide as rapid absorption as the thigh. D: Abdomen - Not ideal due to potential fat layers that could affect absorption speed.
A patient presents at the ED after receiving a chemical burn to the eye. What would be the nurses initial intervention for this patient?
- A. Generously flush the affected eye with a dilute antibiotic solution.
- B. Generously flush the affected eye with normal saline or water.
- C. Apply a patch to the affected eye.
- D. Apply direct pressure to the affected eye.
Correct Answer: B
Rationale: The correct initial intervention for a chemical burn to the eye is to generously flush the affected eye with normal saline or water. Flushing helps to remove the chemical from the eye, preventing further damage. Antibiotic solution (choice A) is not the first intervention as the priority is to remove the chemical. Applying a patch (choice C) can trap the chemical against the eye, worsening the injury. Applying direct pressure (choice D) is not appropriate and can cause additional harm. Flushing with normal saline or water is the most effective and safest initial intervention to minimize damage from a chemical burn to the eye.