Nokea
Following chemotherapy, a patient is being closely monitored for tumor lysis syndrome. Which laboratory value requires particular attention?
- A. Platelet count.
- B. Electrolytes.
- C. Hemoglobin.
- D. Hematocrit.
Correct Answer: B
Rationale: Electrolyte imbalances, particularly hyperkalemia and hyperuricemia, are hallmark features of tumor lysis syndrome and must be closely monitored.
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The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1 piece drainable ostomy pouch. Which is the correct intervention?
- A. Piercing the plastic of the ostomy pouch with a pin to vent the flatus.
- B. Opening the bottom of the pouch, allowing the flatus to be expelled.
- C. Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape.
- D. Assisting the client to ambulate to reduce the flatus in the pouch.
Correct Answer: B
Rationale: Opening the bottom of the pouch allows controlled release of flatus.
Which nursing actions are completed by the scrub nurse (select all that apply)?
- A. Prepares instrument table
- B. Documents intraoperative care
- C. Remains in the sterile area of the OR
- D. Checks mechanical and electrical equipment
Correct Answer: A
Rationale: The scrub nurse manages sterile instruments and assists the surgical team within the sterile field.
Mr. Jones is being discharged today. Which of the following statements by Mr. Jones would indicate that he understands his postoperative regimen?
- A. I'm taking my nephew to the amusement park next week and we are going to ride the roller-coasters.'
- B. My brother will be coming over every day to help me with my bath and to shave me.'
- C. I think I'll watch the baseball games on TV this week rather than driving to the stadium.'
- D. I guess I'll have to take an early retirement since my job as an accountant requires me to use my eyes a lot.'
Correct Answer: C
Rationale: Avoiding strenuous activities like driving or riding roller coasters demonstrates understanding of activity restrictions necessary during recovery from retinal surgery.
Which member of the surgical team does not scrub in the OR?
- A. The surgeon.
- B. The circulating nurse.
- C. The scrub nurse or surgical tech.
- D. The holding area nurse.
Correct Answer: B
Rationale: The circulating nurse remains outside the sterile field to assist with supplies.
Expected age-related changes of the pulmonary system include:
- A. Significant airway obstruction
- B. Shortness of breath
- C. Development of emphysema
- D. A modest,gradual decline in pulmonary function
Correct Answer: D
Rationale: While lung capacity decreases with age, it typically results in a gradual decline rather than significant obstruction or diseases like emphysema unless other factors (e.g., smoking) are present.