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Nurse Gina has also to consider in terms of financial status most of the elderly are
- A. Sufficient
- B. disoriented
- C. Dependent to others financially
- D. Have pension
Correct Answer: C
Rationale: Nurse Gina has to consider that most of the elderly are dependent on others financially. This is an important factor to take into account when planning and providing care for elderly patients. Many elderly individuals rely on financial assistance from family members, government programs, or retirement funds. Understanding the financial status of elderly patients helps nurses like Gina provide adequate care and support to meet their needs effectively. This can involve coordinating with social services or financial assistance programs to ensure that the patients' financial concerns are addressed along with their healthcare needs.
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A patient with osteoarthritis of the hip undergoes surgical intervention with a total hip arthroplasty (THA). Which postoperative complication should the healthcare team monitor for in the immediate postoperative period?
- A. Deep vein thrombosis (DVT)
- B. Delayed wound healing
- C. Pulmonary embolism
- D. Prosthetic joint infection
Correct Answer: A
Rationale: Following total hip arthroplasty (THA), patients are at an increased risk of developing deep vein thrombosis (DVT) due to factors such as immobility, surgery-related vascular damage, and hypercoagulability. DVT refers to the formation of blood clots in the deep veins, typically in the lower extremities. These clots can break loose and travel to the lungs, causing a potentially life-threatening condition called pulmonary embolism (PE). Therefore, monitoring for signs and symptoms of DVT is crucial in the immediate postoperative period to promptly detect and prevent the development of complications such as PE. Common signs of DVT include leg swelling, pain, warmth, and redness. Additionally, healthcare providers may employ preventive measures such as early ambulation, compression stockings, and anticoagulant therapy to reduce the risk of DVT post-THA surgery.
Nurse Gay is assigned in the Medical Unit. She is guided that in documentation, she should use abbreviation that is ______.
- A. used automatically to save precious time.
- B. reduced to the minimum in all units.
- C. approved standard list by the hospital.
- D. not used at all because it can be misinterpreted.
Correct Answer: C
Rationale: Nurse Gay should use abbreviations that are part of an approved standard list by the hospital. Using standardized abbreviations ensures clarity, accuracy, and consistency in documentation. It helps in preventing misinterpretation, errors, and ambiguity in patient records. By following an approved list of abbreviations, healthcare professionals can communicate effectively and efficiently while maintaining patient safety and quality of care.
The INITIAL priority assessment performed by the nurse, when admitting a patients the unit after abdominal surgery is to check for ______.
- A. surgical site for drainage and hemorrhage
- B. skin color and temperature
- C. responsiveness to painful stimuli and noise
- D. respiratory function and airway
Correct Answer: D
Rationale: When admitting a patient to the unit after abdominal surgery, the initial priority assessment performed by the nurse should focus on assessing the patient's respiratory function and airway. This is crucial because post-surgical patients are at risk for complications such as respiratory depression, atelectasis, and airway obstruction. Monitoring the patient's breathing pattern, oxygen saturation levels, and ensuring a patent airway are essential in preventing respiratory distress or failure. Prompt assessment and intervention in this area can help prevent respiratory complications and ensure the patient's safety and well-being. Once the patient's respiratory status is stable, the nurse can then proceed to assess other aspects such as the surgical site, skin color, temperature, and responsiveness to stimuli.
Which of the following laboratory findings is most consistent with acute respiratory distress syndrome (ARDS)?
- A. Elevated serum bicarbonate (HCO3-) level
- B. Decreased serum albumin level
- C. Elevated white blood cell count (WBC)
- D. Increased lactate dehydrogenase (LDH) level
Correct Answer: D
Rationale: Acute respiratory distress syndrome (ARDS) is a severe condition characterized by widespread inflammation in the lungs leading to increased pulmonary vascular permeability, non-cardiogenic pulmonary edema, and respiratory failure. In ARDS, the alveolar-capillary barrier is disrupted, resulting in fluid accumulation in the alveoli and impaired gas exchange.
A nurse is caring for a patient with a history of substance abuse who requests pain medication. What ethical principle should guide the nurse's decision-making in this situation?
- A. Beneficence
- B. Nonmaleficence
- C. Justice
- D. Veracity
Correct Answer: A
Rationale: The ethical principle that should guide the nurse's decision-making in this situation is beneficence, which emphasizes the nurse's obligation to act in the best interest of the patient. In this scenario, the nurse must balance the patient's request for pain medication with considerations related to the patient's history of substance abuse. The nurse should prioritize providing effective pain relief for the patient while also considering the potential risks of administering medication to someone with a history of substance abuse. By focusing on beneficence, the nurse can make decisions that promote the well-being and best interests of the patient, taking into account both the immediate need for pain relief and the patient's history of substance abuse.