Nokea
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.
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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.
A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?
- A. Preparing to administer a barium enema
- B. Withholding narcotic pain medication
- C. Administering laxatives to the patient
- D. Raising the head of the bed
Correct Answer: D
Rationale: Rationale: Option D is correct because raising the head of the bed promotes a more natural position for defecation, allowing gravity to assist. This position helps align the rectum and anal canal, making it easier for the patient to have a bowel movement. Administering laxatives (Option C) may help, but adjusting the bed position is a non-invasive and more immediate intervention. Withholding pain medication (Option B) could lead to unnecessary discomfort for the patient. Administering a barium enema (Option A) is not indicated for addressing difficulty with defecation.
When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?
- A. Loss of muscle tone in the vaginal wall
- B. Excessive synthesis and release of unopposed estrogen
- C. Invasion of the uterine wall by endometrial tissue
- D. Proliferation of tumors in the uterine wall
Correct Answer: C
Rationale: The correct answer is C: Invasion of the uterine wall by endometrial tissue. Adenomyosis is a condition where endometrial tissue grows into the muscular wall of the uterus, causing symptoms like heavy menstrual bleeding and severe cramping. This process results in inflammation, thickening of the uterine wall, and can lead to enlargement of the uterus.
Choice A: Loss of muscle tone in the vaginal wall is incorrect because adenomyosis does not involve the vaginal wall.
Choice B: Excessive synthesis and release of unopposed estrogen is incorrect because although estrogen can contribute to the growth of endometrial tissue, it is not the primary pathophysiologic process in adenomyosis.
Choice D: Proliferation of tumors in the uterine wall is incorrect because adenomyosis does not involve the growth of tumors, but rather the infiltration of endometrial tissue into the uterine muscle.
A nurse is providing care to a culturally diversepopulation. Which action indicates the nurse is successful in the role of providing culturally congruent care?
- A. Provides care that fits the patient’s valued life patterns and set of meanings
- B. Provides care that is based on meanings generated by predetermined criteria
- C. Provides care that makes the nurse the leader in determining what is needed
- D. Provides care that is the same as the values of the professional health care system
Correct Answer: A
Rationale: The correct answer is A because providing care that fits the patient's valued life patterns and set of meanings demonstrates cultural congruence. This approach acknowledges and respects the patient's cultural background, beliefs, and preferences. It promotes patient-centered care and enhances communication and trust between the nurse and the patient.
Choice B is incorrect because care based on predetermined criteria may not align with the patient's individual cultural needs. Choice C is incorrect as it does not prioritize the patient's values and preferences. Choice D is incorrect because providing care based solely on the values of the professional health care system may not consider the cultural diversity of the patient population.
The registered nurse taking shift report learns that an assigned patient is blind. How should the nurse best communicate with this patient?
- A. Provide instructions in simple, clear terms.
- B. Introduce herself in a firm, loud voice at the doorway of the room.
- C. Lightly touch the patients arm and then introduce herself.
- D. State her name and role immediately after entering the patients room.
Correct Answer: A
Rationale: The correct answer is A because providing instructions in simple, clear terms is crucial when communicating with a blind patient. This method allows the patient to understand information effectively without visual cues. Choice B is incorrect because a firm, loud voice may startle the patient. Choice C is incorrect as touching a patient without consent may be inappropriate. Choice D is incorrect because stating name and role without context may confuse the patient.