Nokea
A patient has returned to the post-surgical unit after vulvar surgery. What intervention should the nurse prioritize during the initial postoperative period?
- A. Placing the patient in high Fowlers position
- B. Administering sitz baths every 4 hours
- C. Monitoring the integrity of the surgical site
- D. Avoiding analgesics unless the patients pain is unbearable
Correct Answer: C
Rationale: The correct answer is C: Monitoring the integrity of the surgical site. This is the priority intervention as it ensures early detection of any complications like infection or bleeding. The nurse should assess for signs of infection, such as redness, swelling, or drainage, and monitor for any changes in the wound appearance. Placing the patient in high Fowler's position (A) may be beneficial for comfort but is not the priority. Administering sitz baths (B) may be helpful for comfort but should not be the priority over monitoring the surgical site. Avoiding analgesics (D) unless the pain is unbearable is not appropriate as pain management is essential for the patient's comfort and recovery.
You may also like to solve these questions
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.
A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?
- A. Oral temperature of 100F
- B. Tachypnea and restlessness
- C. Frequent loose stools
- D. Weight loss of 1 pound since yesterday
Correct Answer: B
Rationale: The correct answer is B: Tachypnea and restlessness. This observation takes immediate priority as it indicates potential respiratory distress, a common complication of pneumonia in HIV patients. Tachypnea can be a sign of hypoxia, while restlessness may indicate increased work of breathing. Prompt intervention is crucial to prevent respiratory failure.
Choice A: Oral temperature of 100F is not an immediate priority as it is within normal range and may not directly impact the patient's immediate condition.
Choice C: Frequent loose stools may suggest gastrointestinal issues but are not as urgent as respiratory distress in this scenario.
Choice D: Weight loss of 1 pound since yesterday, while relevant in monitoring the patient's condition, does not require immediate intervention compared to respiratory distress.
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.
A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patients family and friends?
- A. Your family should likely gather at the bedside in case theres a negative outcome.
- B. Make sure she doesnt eat any food in the 24 hours before the procedure.
- C. Wear a hospital gown when you go into the patients room.
- D. Do not visit if youve had a recent infection.
Correct Answer: D
Rationale: The correct answer is D: Do not visit if you've had a recent infection. This is crucial to prevent the transmission of infections to the patient, who will have a compromised immune system post-HSCT. Family and friends with recent infections can pose a serious risk to the patient's health.
Choice A is incorrect because it instills fear and negativity in the family without providing any tangible benefits.
Choice B is incorrect as fasting is not typically required before a HSCT and can be harmful to the patient's nutritional status.
Choice C is incorrect as wearing a hospital gown is generally not necessary for visitors, unless specified by the healthcare team for infection control purposes.
A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the patients preoperative teaching?
- A. The procedure is an effective, time-tested treatment for sensory hearing loss.
- B. The patient is likely to experience resolution of conductive hearing loss after the procedure.
- C. Several months of post-procedure rehabilitation will be needed to maximize benefits.
- D. The procedure is experimental, but early indications suggest great therapeutic benefits.
Correct Answer: B
Rationale: The correct answer is B: The patient is likely to experience resolution of conductive hearing loss after the procedure. This information is crucial to include in the preoperative teaching because it directly addresses the patient's expected outcome, providing reassurance and setting appropriate expectations. Stapedectomy with prosthesis insertion is a well-established treatment for otosclerosis-related conductive hearing loss. Choices A, C, and D are incorrect because they either provide misleading information (A, D) or are not directly relevant to the procedure or the patient's immediate postoperative experience (C). It is important to focus on accurate and relevant information to prepare the patient effectively for the upcoming surgery and its expected outcomes.