Nokea
A patient has just arrived to the floor after an enucleation procedure following a workplace accident in which his left eye was irreparably damaged. Which of the following should the nurse prioritize during the patients immediate postoperative recovery?
- A. Teaching the patient about options for eye prostheses
- B. Teaching the patient to estimate depth and distance with the use of one eye
- C. Assessing and addressing the patients emotional needs
- D. Teaching the patient about his post-discharge medication regimen
Correct Answer: C
Rationale: The correct answer is C: Assessing and addressing the patient's emotional needs. This should be prioritized because the patient has undergone a traumatic experience losing their eye due to a workplace accident. Emotions such as fear, anxiety, and grief are common postoperatively. Addressing these emotional needs is crucial for the patient's overall well-being and recovery. Options A, B, and D are important aspects of care but not the priority in this situation. Teaching about eye prostheses, depth perception, and medication regimen can be addressed once the patient's emotional needs are stabilized.
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During discharge teaching the nurse realizes that the patient is not able to read medication bottles accurately and has not been taking her medications consistently at home. How should the nurse intervene most appropriately in this situation?
- A. Ask the social worker to investigate alternative housing arrangements.
- B. Ask the social worker to investigate community support agencies.
- C. Encourage the patient to explore surgical corrections for the vision problem.
- D. Arrange for referral to a rehabilitation facility for vision training.
Correct Answer: D
Rationale: The correct answer is D. The nurse should arrange for a referral to a rehabilitation facility for vision training. This option directly addresses the patient's inability to read medication bottles accurately due to a vision problem. Vision training can help improve the patient's ability to manage medication independently.
A: Asking the social worker to investigate alternative housing arrangements is not relevant to the patient's vision problem affecting medication management.
B: Asking the social worker to investigate community support agencies may not directly address the patient's vision issue and medication management.
C: Encouraging the patient to explore surgical corrections for the vision problem is not appropriate without considering less invasive options first, such as vision training.
A nurse is caring for a group of patients. Which patient will the nurse seefirst?
- A. Patient receiving total parenteral nutrition of 2-in-1 for 50 hours
- B. Patient receiving total parenteral nutrition infusing with same tubing for 26 hours
- C. Patient receiving continuous enteral feeding with same feeding bag for 12 hours
- D. Patient receiving continuous enteral feeding with same tubing for 24 hours
Correct Answer: B
Rationale: The correct answer is B because the nurse should prioritize the patient who has been receiving total parenteral nutrition (TPN) infusing with the same tubing for 26 hours. This patient needs to be seen first to monitor for any potential complications or issues related to TPN administration. Choice A can be ruled out because 50 hours is longer than 26 hours. Choices C and D involve enteral feeding, which is important but generally less critical than TPN. Additionally, choice D has a shorter duration than choice B. Therefore, choice B is the most time-sensitive and critical patient to assess first.
A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patients care plan addresses the risk of hemorrhage. How should the nurse best monitor the patients postoperative blood loss?
- A. Have the patient void and have bowel movements using a commode rather than toilet.
- B. Count and inspect each perineal pad that the patient uses.
- C. Swab the patients perineum for the presence of blood at least once per shift.
- D. Leave the patients perineum open to air to facilitate inspection.
Correct Answer: B
Rationale: The correct answer is B: Count and inspect each perineal pad that the patient uses. This method directly measures postoperative blood loss and allows for accurate monitoring. It provides quantitative data to assess the severity of hemorrhage.
A: Having the patient void and have bowel movements using a commode rather than toilet does not directly measure blood loss and may not provide accurate monitoring.
C: Swabbing the patient's perineum for the presence of blood is not as accurate as directly counting and inspecting perineal pads.
D: Leaving the patient's perineum open to air does not provide a method for quantifying blood loss and may not be as reliable as inspecting perineal pads.
A nurse is caring for a patient with a continenturinary reservoir. Which action will the nurse take?
- A. Teach the patient how to self-cath the pouch.
- B. Teach the patient how to perform Kegel exercises.
- C. Teach the patient how to change the collection pouch.
- D. Teach the patient how to void using the Valsalva technique. In a continent urinary reservoir, the ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted through the stoma to empty the urine from the pouch. Patients must be willing and able to catheterize the pouch 4 to 6 times a day for the rest of their lives. The second type of continent urinary diversion is called an orthotopic neobladder, which uses an ileal pouch to replace the bladder. Anatomically, the pouch is in the same position as the bladder was before removal, allowing a patient to void through the urethra using a Valsalva technique. In a ureterostomy or ileal conduit the patient has no sensation or control over the continuous flow of urine through the ileal conduit, requiring the effluent (drainage) to be collected in a pouch. Kegel exercises are ineffective for a patient with a continent urinary reservoir.
Correct Answer: A
Rationale: The correct answer is A: Teach the patient how to self-cath the pouch. In a continent urinary reservoir, patients need to catheterize the pouch several times a day. This is essential for emptying the urine from the pouch as the ileocecal valve creates a one-way valve. Teaching the patient how to self-catheterize ensures proper and timely drainage, preventing complications like urinary retention. Self-catheterization also empowers the patient to take an active role in managing their continence.
Summary of other choices:
B: Kegel exercises are ineffective for a patient with a continent urinary reservoir as they do not address the need for catheterization.
C: Changing the collection pouch is not the primary action needed for a continent urinary reservoir. Catheterization is essential for drainage.
D: The Valsalva technique is not appropriate for voiding in a continent urinary reservoir. Catheterization is the recommended method for emptying the pouch.
A nurse is preparing to lavage a patient in theemergency department for an overdose. Which tube should the nurse obtain?
- A. Ewald
- B. Dobhoff
- C. Miller-Abbott
- D. Sengstaken-Blakemore
Correct Answer: A
Rationale: The correct answer is A: Ewald tube. This tube is used for gastric lavage due to its large diameter and open end which allows for effective suction of gastric contents. The Ewald tube is specifically designed for gastric lavage and is ideal for removing toxins from the stomach.
Summary of why the other choices are incorrect:
B: Dobhoff tube is a small-bore feeding tube, not suitable for gastric lavage.
C: Miller-Abbott tube is used for intestinal decompression, not gastric lavage.
D: Sengstaken-Blakemore tube is used for esophageal varices, not gastric lavage.