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A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do?
- A. Call the physician and ask for the order to be confirmed.
- B. Follow the order because this position will help keep the retinal repair intact.
- C. Instruct the patient to maintain this position to prevent bleeding.
- D. Reposition the patient after the first dressing change.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Prone position post retinal detachment repair helps the gas bubble or silicone oil stay against the retina to support healing.
2. This position prevents the bubble/oil from moving and causing further detachment.
3. Repositioning can jeopardize the surgical repair and lead to complications.
4. Calling the physician (A) is unnecessary as the order is clear.
5. Instructing the patient to prevent bleeding (C) is not related to the positioning after retinal detachment repair.
6. Repositioning after the first dressing change (D) contradicts the initial order and risks complications.
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A nurse is preparing a bowel training programfor a patient. Which actions will the nurse take? (Select all that apply.)
- A. Record times when the patient is incontinent.
- B. Help the patient to the toilet at the designated time.
- C. Lean backward on the hips while sitting on the toilet.
- D. Maintain normal exercise within the patient’s physical ability.
Correct Answer: A
Rationale: The correct answer is A. Recording times when the patient is incontinent is crucial in identifying patterns and establishing a structured bowel training program. This data helps in determining the optimal timing for toileting. Choices B, C, and D are incorrect. Choice B is not specific to bowel training and may not address the patient's individual needs. Choice C is not a recommended posture for effective bowel elimination. Choice D, while important for overall health, is not directly related to bowel training.
Which nursing actions will the nurse implementwhen collecting a urine specimen from a patient? (Select all that apply.)
- A. Growing urine cultures for up to 12 hours
- B. Labeling all specimens with date, time, and initials
- C. Allowing the patient adequate time and privacy to void
- D. Wearing gown, gloves, and mask for all specimen handling
Correct Answer: B
Rationale: The correct answer is B: Labeling all specimens with date, time, and initials. This is important for proper identification and tracking of the specimen.
- Choice A is incorrect because urine cultures typically take longer than 12 hours to grow.
- Choice C is incorrect as privacy is important but not a specific action related to urine specimen collection.
- Choice D is incorrect as wearing gown, gloves, and mask may not be necessary for routine urine specimen collection, unless there are specific precautions needed.
Which finding would indicate concealed hemorrhage in abruptio placentae?
- A. Bradycardia
- B. Hard boardlike abdomen
- C. Decrease in fundal height
- D. Decrease in abdominal pain
Correct Answer: B
Rationale: The correct answer is B: Hard boardlike abdomen. In abruptio placentae, concealed hemorrhage can lead to blood accumulating behind the placenta, causing the uterus to become tense and rigid, resulting in a hard boardlike abdomen. This finding indicates significant internal bleeding and requires immediate medical attention.
Rationale:
A: Bradycardia is a slow heart rate and is not typically associated with concealed hemorrhage in abruptio placentae.
C: Decrease in fundal height may indicate intrauterine growth restriction, not specifically concealed hemorrhage.
D: Decrease in abdominal pain is not a typical indicator of concealed hemorrhage; in fact, pain may increase due to the increased pressure in the uterus from the bleeding.
The nurse is caring for patients with ostomies.In which ostomy location will the nurse expect very liquid stool to be present?
- A. Sigmoid
- B. Transverse
- C. Ascending
- D. Descending
Correct Answer: C
Rationale: The correct answer is C: Ascending. Stool consistency varies based on the location of the ostomy. The ascending colon is responsible for absorbing water from stool, so an ostomy in this location will have very liquid stool. Sigmoid, transverse, and descending colons are responsible for further solidifying stool, so ostomies in those locations would not typically have very liquid stool.
The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what potential complications?
- A. Vertebral fracture
- B. Hematoma at the surgical site
- C. Scoliosis
- D. Renal trauma
Correct Answer: B
Rationale: The correct answer is B: Hematoma at the surgical site. This is a potential complication of cervical discectomy due to the risk of bleeding post-surgery. Hematoma can compress nearby structures and lead to increased pain and swelling.
A: Vertebral fracture is not a typical complication of cervical discectomy, as the surgery aims to relieve pressure on the spinal cord caused by a herniated disc, not to cause fractures.
C: Scoliosis is a condition characterized by abnormal lateral curvature of the spine, and it is not directly related to cervical discectomy.
D: Renal trauma is not a common complication of cervical discectomy, as the surgery focuses on the cervical spine and does not involve the kidneys or renal system.