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Patients are at risk for overwhelming postsplenectomy infection (OPSI) following splenectomy. Which of the ff. symptoms alerts the nurse to this possibility?
- A. Bruising around the operative site
- B. Pain
- C. Irritability
- D. Fever
Correct Answer: D
Rationale: The correct answer is D: Fever. Following splenectomy, patients are at risk for OPSI due to impaired immune response. Fever is a key symptom of infection and should alert the nurse to this possibility. Bruising around the operative site (A) is expected post-surgery. Pain (B) is common after surgery and may not specifically indicate OPSI. Irritability (C) is a vague symptom and not specific to OPSI. In summary, fever is the most concerning symptom as it can indicate an underlying infection in a postsplenectomy patient.
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Which of the ff. subjective data questions would assist the nurse in assessing the patient’s eye health?
- A. “Have you had any recent upper respiratory infections?”
- B. “Have you ridden in a car recently?”
- C. “Have you been scuba diving lately?”
- D. “Have you seen halos around lights?”
Correct Answer: D
Rationale: The correct answer is D. Asking about seeing halos around lights is relevant to assessing the patient's eye health as it could indicate conditions like glaucoma or cataracts. Upper respiratory infections (A), riding in a car (B), and scuba diving (C) are not directly related to eye health assessment. By focusing on symptoms directly related to the eyes, the nurse can gather relevant information for a more accurate assessment.
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
- A. Proceed to the next patient’s room to make rounds.
- B. Determine the patient does not want any pain medicine.
- C. Ask the patient about the facial grimacing with movement.
- D. Administer the pain medication ordered for moderate to severe pain.
Correct Answer: C
Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is because the patient's non-verbal cues (facial grimacing) are contradicting their verbal report of low pain level. By asking the patient directly, the nurse can clarify the discrepancy and gain a better understanding of the patient's actual pain level and needs.
Choice A is incorrect as it disregards the patient's observed discomfort. Choice B assumes the patient does not want pain medicine without clarifying the situation first. Choice D is premature as administering pain medication without further assessment may not be appropriate or safe.
In summary, asking the patient about the facial grimacing is essential to ensure accurate pain assessment and appropriate intervention.
The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
- A. Central venous pressure (CVP)
- B. Pulmonary artery capillary pressure (PACP)
- C. Pulmonary artery obstructive pressure (PACP)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The correct answer is C: Pulmonary artery obstructive pressure (PACP). The multilumen pulmonary artery catheter measures hemodynamic pressures in the heart. When the catheter tip enters small branches of the pulmonary artery, it can assess Central Venous Pressure (A), Pulmonary Artery Capillary Pressure (B), and Pulmonary Artery Wedge Pressure (D). Pulmonary artery obstructive pressure is not a standard hemodynamic measurement and is not assessed using this catheter. It is crucial to differentiate between the various pressures measured to accurately assess the patient's cardiac status.
A client has had heavy menstrual bleeding for 6 months. Her gynecologist diagnoses microcytic hypochromic anemia and prescribes ferrous sulfate (Feosol), 300mg PO daily. Before initiating iron therapy, the nurse reviews the client’s medical history. Which condition would contraindicate the use of ferrous sulfate?
- A. Pregnancy
- B. Ulcerative colitis
- C. Asthma
- D. Severely impaired liver function
Correct Answer: B
Rationale: The correct answer is B: Ulcerative colitis. Iron therapy can exacerbate gastrointestinal issues, including ulcerative colitis due to its potential to cause irritation and inflammation in the digestive tract. This can lead to worsening symptoms and complications for the client.
A: Pregnancy is not a contraindication for iron therapy; in fact, it is commonly prescribed during pregnancy to prevent or treat anemia.
C: Asthma is not a contraindication for iron therapy as it does not directly interact with asthma or its treatment.
D: Severely impaired liver function is not a direct contraindication for iron therapy, although caution may be needed in such cases due to iron metabolism being affected by liver function.
A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client’s history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis?
- A. A seizure disorder
- B. Anemia
- C. Chronic obstructive pulmonary disease
- D. A bleeding disorder
Correct Answer: D
Rationale: The correct answer is D: A bleeding disorder. Thoracentesis involves inserting a needle into the pleural space to remove fluid. A bleeding disorder increases the risk of excessive bleeding during the procedure. This can lead to complications such as hematoma formation, pneumothorax, or even life-threatening bleeding. It is crucial to assess and address bleeding disorders before performing thoracentesis to ensure the safety of the client.
A: A seizure disorder is not a contraindication for thoracentesis unless uncontrolled seizures could compromise the safety of the procedure.
B: Anemia alone is not a contraindication for thoracentesis, as it does not directly increase the risk of complications during the procedure.
C: Chronic obstructive pulmonary disease is not a contraindication for thoracentesis unless it is severe and compromises the client's ability to tolerate the procedure.