Nokea
Clients will go through operations and who have undergone surgery need the proper observation, treatment, and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria is preparing Mr. Sy for surgery. Which of the following statements by the client would indicate he is well-informed about his imminent surgery?
- A. “ Right after the operation, I will wear the pneumatic compression device while sitting on the chair.”
- B. “I will not eat anything after 12 pm the night befire my operation, but I sure can drink.”
- C. “The skin preparation site is longer and wider than the actual incision site.”
- D. “I will need to sign the consent from after I get to the operating table.”
Correct Answer: B
Rationale: The correct answer is B. Mr. Sy's statement indicates he understands the pre-operative fasting instructions, which is crucial to prevent aspiration during surgery. Not eating after midnight reduces the risk of complications.
A: Incorrect. Wearing a pneumatic compression device post-surgery is important, but this statement does not demonstrate understanding of pre-surgery preparations.
C: Incorrect. Knowing the skin preparation site size does not indicate understanding of the surgery process.
D: Incorrect. Signing the consent form at the operating table may indicate lack of understanding of the consent process and timing.
In summary, choice B is correct as it shows Mr. Sy's awareness of the fasting requirement before surgery, which is crucial for a safe operation.
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Aling Nena, 68 years old, had a MVA and underwent surgery for hip fracture. Two days post-surgery, she suddenly complained of chest heaviness despite the absence of cardiac history. What is the nursing priority?
- A. document the onset, duration, severity, and precipitating factors
- B. may offer analgesics for chest pain
- C. administer oxygen via face mask
- D. inform the physician about the heaviness
Correct Answer: C
Rationale: The correct answer is C: administer oxygen via face mask. Given Aling Nena's sudden chest heaviness post-surgery, oxygen administration is the priority to ensure adequate oxygenation. This can help rule out potential respiratory issues or hypoxemia, which are common post-operatively. Providing oxygen promptly can prevent further complications such as respiratory distress or cardiac compromise. Documenting the pain characteristics (choice A) can be done after ensuring immediate physiological needs are met. Offering analgesics (choice B) without confirming the underlying cause can mask symptoms and delay appropriate interventions. Informing the physician (choice D) is important but not as urgent as addressing potential respiratory compromise.
Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
- A. Level of awareness and response to pain
- B. Papillary reflexes and response to sensory stimuli
- C. Coherence and sense of hearing
- D. Patency of airway and adequacy of respiration
Correct Answer: D
Rationale: The correct answer is D: Patency of airway and adequacy of respiration. During the acute stage of an unconscious patient like Mr. Franco, ensuring the airway is open and that breathing is adequate is the top priority to maintain oxygenation and prevent complications like hypoxia. This assessment is crucial for immediate intervention and can be life-saving.
A: Level of awareness and response to pain may provide important information but is secondary to ensuring a patent airway and adequate breathing in an unconscious patient.
B: Pupillary reflexes and response to sensory stimuli are important neurological assessments, but airway and breathing take precedence in the acute stage to maintain vital functions.
C: Coherence and sense of hearing are not as critical as assessing and maintaining the airway and breathing in an unconscious patient.
A female client with lymphedema expresses her anxiety about the abnormal enlargement of an arm. Which of the ff suggestions should a nurse give to support the clients self image?
- A. Place the arm in the sling
- B. Apply cold soaks to the affected arm
- C. Introduce variations in styles of clothing
- D. Tie a tight bandage to the arm
Correct Answer: C
Rationale: The correct answer is C: Introduce variations in styles of clothing. This suggestion promotes the client's self-image by helping her feel more comfortable and confident in her appearance despite the lymphedema. It allows her to express her personal style while accommodating the enlarged arm.
A: Placing the arm in a sling does not address the client's self-image concerns and may further highlight the abnormality.
B: Applying cold soaks may help with swelling but does not directly address the client's self-image.
D: Tying a tight bandage can worsen lymphedema and does not address the client's self-image concerns.
A 36 y.o. woman who has had no prenatal care comes into the hospital in active labor for her fourth child. She has vesicles evident on her perineum. The following nursing actions are appropriate to protect the unborn baby and the staff, EXCEPT:
- A. Maintain standard precautions
- B. Prepare for the possibility that the baby may be delivered by CS.
- C. Notify the obstetrician and nurse midwife about the vesicles as soon as possible.
- D. Apply antibiotic ointment to the vesicles and place the mother in reverse isolation
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Applying antibiotic ointment and placing the mother in reverse isolation are not appropriate for managing vesicles suspected to be herpes simplex virus (HSV) during labor.
2. HSV can be transmitted to the baby during vaginal delivery, leading to serious consequences.
3. Standard precautions should always be maintained to prevent the spread of infections.
4. Preparing for the possibility of a cesarean section and notifying the obstetrician about the vesicles are important steps to protect the baby and staff from potential harm.
Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects would you anticipate from too rapid infusion rate?
- A. Cellular dehydration and potassium
- B. Hypoglycemia and hypovolemia
- C. Potassium excess and CHF
- D. Circulatory overload and hypoglycemia SITUATION: In the recall of the fluids and electrolytes, the nurse should be able to understand the calculations and other conditions related to loss or retention.
Correct Answer: D
Rationale: Rationale:
1. Rapid infusion of hyperalimentation solutions can lead to circulatory overload due to increased fluid volume in the circulatory system.
2. Circulatory overload can result in symptoms such as hypertension, tachycardia, and edema.
3. Hypoglycemia can occur as a result of excess insulin release due to the sudden increase in glucose from the hyperalimentation solution.
Summary:
A. Cellular dehydration and potassium: Incorrect. Rapid infusion would lead to fluid overload, not dehydration.
B. Hypoglycemia and hypovolemia: Incorrect. Hypovolemia is unlikely with rapid infusion, and hypoglycemia is a possible side effect.
C. Potassium excess and CHF: Incorrect. Rapid infusion may cause circulatory overload, not CHF, and potassium excess is not a common side effect.
D. Circulatory overload and hypoglycemia: Correct. These are the most likely side effects of rapid