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A patient is being discharged home after a hysterectomy. When providing discharge education for this patient, the nurse has cautioned the patient against sitting for long periods. This advice addresses the patients risk of what surgical complication?
- A. Pudendal nerve damage
- B. Fatigue
- C. Venous thromboembolism
- D. Hemorrhage
Correct Answer: C
Rationale: The correct answer is C: Venous thromboembolism. After a hysterectomy, patients are at increased risk for developing blood clots due to decreased mobility and pressure on the veins. Sitting for long periods can further increase this risk by slowing blood flow. Pudendal nerve damage (A) is not a common complication of hysterectomy. Fatigue (B) is a common postoperative symptom but not directly related to sitting for long periods. Hemorrhage (D) is a potential complication of hysterectomy but is not specifically related to sitting for long periods.
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A patient has been brought to the emergency department by EMS after being found unresponsive. Rapid assessment reveals anaphylaxis as a potential cause of the patients condition. The care team should attempt to assess for what potential causes of anaphylaxis? Select all that apply.
- A. Foods
- B. Medications
- C. Insect stings
- D. Autoimmunity E) Environmental pollutants
Correct Answer: A
Rationale: The correct answer is A: Foods. Anaphylaxis is a severe allergic reaction that can be triggered by foods, medications, insect stings, and other allergens. In this scenario, assessing for potential food allergies is crucial as food is one of the most common triggers for anaphylaxis. Foods like nuts, shellfish, and eggs are common culprits. Medications and insect stings (choices B and C) are also important triggers to consider in the assessment. Autoimmunity (choice D) is not a direct cause of anaphylaxis, as it involves the immune system attacking the body's own tissues rather than reacting to external allergens. Environmental pollutants (choice E) may trigger respiratory symptoms but are not typically associated with anaphylaxis.
The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching?
- A. Try to induce a sneeze every 4 hours to equalize pressure.
- B. Be sure to exercise to reduce fatigue.
- C. Avoid sleeping in a side-lying position.
- D. Dont blow your nose for 2 to 3 weeks.
Correct Answer: D
Rationale: The correct answer is D: "Don't blow your nose for 2 to 3 weeks." After mastoid surgery, blowing the nose can increase pressure in the surgical area and disrupt healing. Here's the rationale:
1. Blowing the nose can increase pressure in the surgical area and lead to complications.
2. Avoiding blowing the nose helps prevent infection and reduces the risk of damaging the surgical site.
3. It is essential to follow this instruction to promote proper healing and reduce the chances of postoperative complications.
In summary, the other choices are incorrect because inducing a sneeze, exercising, and avoiding side-lying position do not directly relate to the specific care needs after mastoid surgery.
The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. What does the nurse suspect is themostlikely cause of the diarrhea?
- A. Antibiotic therapy
- B. Clostridium difficile
- C. Formula intolerance
- D. Bacterial contamination
Correct Answer: C
Rationale: The correct answer is C: Formula intolerance. When a patient develops diarrhea shortly after starting enteral feeding, formula intolerance is the most likely cause. This can occur due to the patient's inability to tolerate certain ingredients in the formula, leading to gastrointestinal upset. Antibiotics (choice A) and Clostridium difficile (choice B) typically take longer to cause diarrhea. Bacterial contamination (choice D) would usually result in more severe symptoms beyond just diarrhea. In this scenario, formula intolerance is the most logical explanation for the immediate onset of diarrhea after starting enteral feeding.
A patient at high risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the patient asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurses best response?
- A. An incisional biopsy is performed because its known to be less painful and more accurate than other forms of testing.
- B. An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment.
- C. An incisional biopsy is performed to assess the potential for recovery from a mastectomy.
- D. An incisional biopsy is performed on patients who are younger than the age of 40 and who are otherwise healthy.
Correct Answer: B
Rationale: The correct answer is B because an incisional biopsy is typically performed to confirm a diagnosis by obtaining a sample of the tissue in question. This allows for further analysis through special studies to determine the best course of treatment. The other choices are incorrect because:
A: The reason for performing an incisional biopsy is not primarily based on pain or accuracy comparisons with other testing methods.
C: An incisional biopsy is not done to assess potential recovery from a mastectomy but rather to diagnose the nature of the mass.
D: Age and general health status are not sole criteria for determining the need for an incisional biopsy.
The clinic nurse is performing a prenatal assessment on a pregnant patient at risk for preeclampsia. Which clinical sign would not present as a symptom of preeclampsia?
- A. Edema
- B. Proteinuria
- C. Glucosuria
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C, Glucosuria. Preeclampsia is characterized by hypertension, proteinuria, and edema. Glucosuria is not a typical symptom of preeclampsia. Glucosuria is more commonly associated with gestational diabetes, which is a separate condition from preeclampsia. Therefore, in a pregnant patient at risk for preeclampsia, the presence of glucosuria would not be indicative of preeclampsia. The other choices, edema, proteinuria, and hypertension, are all common clinical signs seen in patients with preeclampsia.