Nokea
During surgery, a patient has a nursing diagnosis of risk for perioperative positioning injury. What is a common risk factor for this nursing diagnosis?
- A. Skin lesions
- B. Break in sterile technique
- C. Musculoskeletal deformities
- D. Electrical or mechanical equipment failure
Correct Answer: C
Rationale: Musculoskeletal deformities increase the risk of positioning injuries during surgery.
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Mrs. Roberts communicates very well by lipreading. In planning Mrs. Roberts' care, it is important to
- A. face her and slightly raise your voice
- B. write everything important
- C. employ nonverbal cues to help convey your meaning
- D. avoid obscuring her view of your mouth
Correct Answer: D
Rationale: Clear visibility of the speaker's mouth is vital for effective lipreading, ensuring accurate communication.
During an ophthalmic assessment, which of the following is the nurse expected to observe carefully?
- A. Level of central vision
- B. Internal eye condition
- C. Pupil responses
- D. Rate of blinking
Correct Answer: C
Rationale: Pupil responses are critical in assessing neurological and ocular health. They provide important clues about potential disorders.
Joan is diagnosed with a gastric ulcer. What symptoms would she exhibit?
- A. Epigastric pain worse before meals, pain on awakening, and melena.
- B. Decreased bowel sounds, rigid abdomen, rebound tenderness, and fever.
- C. Boring epigastric pain radiating to back and left shoulder, bluish-gray discoloration of periumbilical area, and ascites.
- D. Epigastric pain that is worse after eating and weight loss.
Correct Answer: A
Rationale: Gastric ulcers typically cause pain before meals and at night.
A 27-year-old client who is three hours postoperative complains of right leg pain after knee reduction surgery. The first action by the nurse should be to:
- A. assess vital signs.
- B. elevate the extremity.
- C. perform a lower extremity neurovascular check.
- D. remind the client of the PCA pump and re-instruct the client on its use.
Correct Answer: C
Rationale: Vital signs may be altered if there is acute pain or complications related to bleeding or swelling, but it should not be assessed before checking the affected extremity. The extremity can be elevated if ordered by the physician. Assessment of the postoperative area is important to determine the presence of bleeding, swelling, or decreased circulation. Reinforcement of teaching on the use of the patient-controlled anesthesia (PCA) pump is important, but it is not the first action.
Identify one example of how each of the following cultural factors may affect the nursing care of a patient of a different culture and one example of the functioning of a health care team made up of individuals from different cultures.
- A. Time orientation
- B. Economic factors
- C. Nutrition
- D. Personal space
Correct Answer: D
Rationale: This question requires subjective examples based on individual interpretation. For instance, time orientation might influence punctuality expectations in patients and collaboration within diverse teams.