Nokea
The nurse assessing a postoperative patient discovers that the pulse is rapid blood pressure has decreased urinary output has decreased and the dressing is dry. What can the nurse determine is indicated by these findings?
- A. Pain shock
- B. Dehydration
- C. Internal hemorrhage
- D. Acute infection
Correct Answer: C
Rationale: If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage.
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When removing the dressing on a patient the nurse discovers that the gauze dressing has adhered to the wound. What intervention should the nurse implement?
- A. Call the RN.
- B. Gently remove the gauze with sterile forceps.
- C. Cover with occlusive dressing.
- D. Moisten the dressing with sterile water.
Correct Answer: D
Rationale: When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it.
The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change?
- A. After the dressing change
- B. At least 15 minutes before the dressing change
- C. At least 30 minutes before the dressing change
- D. At least 1 hour before the dressing change
Correct Answer: C
Rationale: It may help to give an analgesic at least 30 minutes before exposing the wound.
The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus?
- A. Improves overall tissue perfusion.
- B. Promotes release of oxygen to tissues.
- C. Causes hemoglobin to have a greater affinity for oxygen.
- D. Causes hemoglobin to have a decreased affinity for oxygen.
Correct Answer: C
Rationale: Diabetes mellitus is a chronic disease that causes small blood vessel disease that impairs tissue perfusion. It also causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues.
The day following surgery the nurse notes bloody drainage on the dressing. How will the nurse describe this drainage when documenting?
- A. Serosanguineous
- B. Sanguineous
- C. Serous
- D. Purulent
Correct Answer: B
Rationale: The term sanguineous means bloody. It is indicative of active bleeding.
The nurse is instructing a patient about the effects of smoking. What accurate information does the nurse provide?
- A. Smoking increases the amount of tissue oxygenation.
- B. Smoking increases the amount of functional hemoglobin in blood.
- C. Smoking may decrease platelet aggregation and cause hypercoagulability.
- D. Smoking interferes with normal cellular mechanisms that promote release of oxygen.
Correct Answer: D
Rationale: Smoking reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Smoking may increase platelet aggregation and hypercoagulability. Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissues.