Nokea
A patient has returned to the floor from the PACU after undergoing a suprapubic prostatectomy. The nurse notes significant urine leakage around the suprapubic tube. What is the nurses most appropriate action?
- A. Cleanse the skin surrounding the suprapubic tube.
- B. Inform the urologist of this finding.
- C. Remove the suprapubic tube and apply a wet-to-dry dressing.
- D. Administer antispasmodic drugs as ordered.
Correct Answer: B
Rationale: The correct answer is B: Inform the urologist of this finding. In this scenario, significant urine leakage around the suprapubic tube indicates a potential issue with the tube placement or functioning. It is crucial to involve the urologist, who is the specialist managing the patient's urological interventions, to assess and address the cause of the leakage promptly. This action ensures timely and appropriate intervention to prevent complications such as infection or further damage.
Choice A is incorrect because simply cleansing the skin does not address the underlying issue of urine leakage. Choice C is incorrect and potentially harmful as removing the suprapubic tube without professional assessment can lead to serious complications. Choice D is incorrect as administering antispasmodic drugs may not be the appropriate action without further evaluation by the urologist.
You may also like to solve these questions
A nurse wants to find the daily weights of apatient. Which form will the nurse use?
- A. Database
- B. Progress notes
- C. Patient care summary
- D. Graphic record and flow sheet
Correct Answer: D
Rationale: The correct answer is D: Graphic record and flow sheet. The nurse will use a graphic record and flow sheet to document the patient's daily weights. This form allows for easy tracking and visualization of weight trends over time. Database (A) is used for storing large amounts of data but not ideal for daily weight tracking. Progress notes (B) are for narrative descriptions of patient care, not specific for daily weights. Patient care summary (C) provides an overview of the patient's care plan, not detailed daily weights.
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 nurse is assessing a patient who presented to the ED with priapism. The student nurse is aware that this condition is classified as a urologic emergency because of the potential for what?
- A. Urinary tract infection
- B. Chronic pain
- C. Permanent vascular damage
- D. Future erectile dysfunction
Correct Answer: C
Rationale: The correct answer is C: Permanent vascular damage. Priapism is a prolonged erection that can lead to ischemia and damage to the penile tissue due to impaired blood flow, potentially resulting in permanent vascular damage. Urinary tract infection (A) is unrelated to priapism. Chronic pain (B) may occur but is not the primary concern. Future erectile dysfunction (D) can result from priapism but is not as immediate or severe as permanent vascular damage. Therefore, C is the most critical consequence to address in priapism.
The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action?
- A. Placing the patient in a prone position
- B. Assisting the patient into a sitting position
- C. Instilling 15 mL of warm normal saline into one of the patients ears
- D. Assessing the patients baseline hearing by performing the whisper test
Correct Answer: B
Rationale: The correct answer is B: Assisting the patient into a sitting position. The Epley maneuver is used to treat benign paroxysmal positional vertigo by repositioning displaced calcium carbonate crystals in the inner ear. This maneuver involves a series of specific head movements. Starting with the patient in a sitting position allows for proper orientation and positioning for subsequent movements to be effective. Placing the patient in a prone position (A) would not facilitate the correct positioning for the maneuver. Instilling warm saline into the ear (C) is not part of the Epley maneuver. Assessing baseline hearing (D) is unrelated to performing the Epley maneuver.
The nurse is providing care for a patient who has a diagnosis of hereditary angioedema. When planning this patients care, what nursing diagnosis should be prioritized?
- A. Risk for Infection Related to Skin Sloughing
- B. Risk for Acute Pain Related to Loss of Skin Integrity
- C. Risk for Impaired Skin Integrity Related to Cutaneous Lesions
- D. Risk for Impaired Gas Exchange Related to Airway Obstruction
Correct Answer: D
Rationale: The correct answer is D: Risk for Impaired Gas Exchange Related to Airway Obstruction. This should be prioritized because hereditary angioedema can lead to swelling in the airway, potentially causing respiratory distress and compromising gas exchange. This nursing diagnosis addresses the immediate threat to the patient's respiratory function.
A: Risk for Infection Related to Skin Sloughing - While skin sloughing can occur with hereditary angioedema, it is not the priority over ensuring adequate gas exchange.
B: Risk for Acute Pain Related to Loss of Skin Integrity - Pain management is important, but addressing airway obstruction takes precedence due to the potential for respiratory compromise.
C: Risk for Impaired Skin Integrity Related to Cutaneous Lesions - Skin integrity issues may be present but do not pose as immediate a threat as airway obstruction.