Nokea
A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what?
- A. Slight morning discharge from the eye
- B. Any appearance of redness of the eye
- C. A scratchy feeling in the eye
- D. A new floater in vision
Correct Answer: B
Rationale: Redness of the eye after cataract surgery can be a sign of infection or inflammation, which are serious complications that require immediate medical attention. Redness may be accompanied by pain, swelling, or discharge, and if left untreated, it can lead to complications that may affect the surgical outcome and the patient's vision. Therefore, it is crucial for the patient to contact the office immediately if they notice any redness in their eye following cataract surgery.
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The nurse is providing discharge education for a patient with a new diagnosis of Mnires disease. What food should the patient be instructed to limit or avoid?
- A. Sweet pickles
- B. Frozen yogurt
- C. Shellfish
- D. Red meat
Correct Answer: C
Rationale: Patients with Meniere's disease are often advised to limit their intake of salt as excess salt can worsen symptoms such as dizziness and vertigo. Shellfish tend to be high in sodium, so patients with Meniere's disease should be instructed to avoid or limit their consumption of shellfish to help manage their condition. It is important for the nurse to provide comprehensive diet education to the patient to help them minimize symptoms and improve their overall quality of life.
A male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first?
- A. Perform oral suctioning.
- B. Page the physician.
- C. Insert a tongue depressor into the patients mouth.
- D. Turn the patient on his side.
Correct Answer: D
Rationale: When a patient is experiencing a seizure and begins vomiting, the priority action for the nurse is to turn the patient onto their side. This position helps to prevent aspiration, which can occur when the patient inhales vomit into their lungs. Turning the patient on their side allows for the vomit to drain out of the mouth, reducing the risk of aspiration and maintaining a clear airway. Performing oral suctioning would be necessary after turning the patient on their side, but it is not the initial priority in this situation. Paging the physician and inserting a tongue depressor are not appropriate actions during a seizure and vomiting episode.
Which assessment by the nurNseU wRoSuIldN dGiffTerBen.tiCatOe Ma placenta previa from an abruptio placentae?
- A. Saturated perineal pad in 1 hour
- B. Pain level 0 on a scale of 0 to 10
- C. Cervical dilation at 2 cm
- D. Fetal heart rate at 160 bpm
Correct Answer: A
Rationale: In the assessment of a patient with potential placenta previa or abruptio placentae, the nurse should pay close attention to the amount and characteristics of vaginal bleeding. Placenta previa typically presents with painless vaginal bleeding, which can be sudden and significant. Therefore, a saturated perineal pad within a short period of time (1 hour) is more indicative of placenta previa, as opposed to abruptio placentae which usually presents with painful vaginal bleeding and may not necessarily saturate a perineal pad quickly. Monitoring the amount of bleeding and keeping track of pad saturation over time can provide valuable information to differentiate between these two conditions.
The nurse is caring for a patient with an advanced stage of breast cancer and the patient has recently learned that her cancer has metastasized. The nurse enters the room and finds the patient struggling to breath and the nurses rapid assessment reveals that the patients jugular veins are distended. The nurse should suspect the development of what oncologic emergency?
- A. Increased intracranial pressure
- B. Superior vena cava syndrome (SVCS)
- C. Spinal cord compression
- D. Metastatic tumor of the neck
Correct Answer: B
Rationale: Superior vena cava syndrome (SVCS) is a medical emergency that can occur in patients with advanced cancer, such as breast cancer with metastasis. SVCS is caused by the obstruction or compression of the superior vena cava, a large vein that carries blood from the upper body back to the heart. When the superior vena cava is obstructed or compressed, it can lead to symptoms such as difficulty breathing (dyspnea) and distended jugular veins.
A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The patient is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment?
- A. Gag reflex
- B. Deep tendon reflexes
- C. Abdominal girth
- D. Hearing acuity
Correct Answer: A
Rationale: The most critical assessment parameter to include in the initial assessment of a patient with a brain tumor scheduled for surgery is the gag reflex. The gag reflex is a protective mechanism that prevents the entry of foreign objects into the airway and lungs. Patients undergoing brain tumor resection may be at risk for impaired gag reflex due to the effects of the tumor on cranial nerves or related structures. Identifying any impairment in the gag reflex is essential to prevent aspiration during and after the surgical procedure. Monitoring the gag reflex allows the healthcare team to take necessary precautions to protect the patient's airway and prevent complications. Therefore, assessing the gag reflex is crucial in the care of a patient with a brain tumor undergoing surgery.