Nokea
A patient 48 hours after surgery for a hernia repair.
The nurse checks the incision of a patient 48 hours after surgery for a hernia repair. Which of the following findings would indicate a possible complication?
- A. There is swelling under the sutures.
- B. There is crusting around the incision line.
- C. The incision line is red.
- D. The incision line is approximated.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice. (1) slight swelling is expected during healing (2) slight crusting of incision line is normal (3) correct-should be pink, not red, indicates possible infection, other signs include increased warmth, tenderness, pain, and purulent or odorous drainage (4) shows healing is taking place
You may also like to solve these questions
A high school nurse observes a 14 year-old female rubbing her scalp excessively in the gym. The most appropriate course of action for the nurse to do is:
- A. Request a private evaluation of the female's scalp from her parents.
- B. Contact the female's parents about the observations.
- C. Observe the hairline and scalp for possible signs of lice.
- D. Contact the student's physician.
Correct Answer: C
Rationale: Observation of the student's hair is the next step.
A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm³, WBC 3,000/mm³, Hgb 9.3 g/dL, platelets 50,000/mm³.
The nurse would expect the patient to exhibit which of the following symptoms?
- A. BP 120/70, pulse 100, respirations 16.
- B. Ankle edema and ascites.
- C. Flushed face and light stools.
- D. Nausea, anorexia, and vomiting.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the situation. (1) correct-increased pulse and respirations are caused by decreased oxygenation of tissues (2) no information to suggest this is provided in the question (3) will be pale due to anemia, normal RBC male 4.3-5.9 million/mm³, female 3.5-5.5 million/mm³, decreased with anemia; normal WBC 4,500-11,000/mm³, decreased (leukopenia) causes susceptibility to infection; normal Hgb - male 13.5-17.5 g/dL, female 12-16 g/dL, decreased with anemia (4) not related to information provided in the question
The nurse is caring for a client with a history of bipolar disorder who is receiving lithium 300 mg PO tid. Which of the following symptoms should the nurse report immediately?
- A. Mild thirst.
- B. Tremors and confusion.
- C. Occasional diarrhea.
- D. Dry mouth.
Correct Answer: B
Rationale: Tremors and confusion suggest lithium toxicity, a medical emergency. Options A, C, and D are common side effects.
Before administering calcium gluconate 10% 500 mg IV stat.
It is MOST important that the nurse assess the
- A. stability of the respiratory system.
- B. adequacy of urine output.
- C. patency of the vein.
- D. availability of magnesium sulfate injection.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct-if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant
A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to
- A. Suggest 3 to 4 warm sitz baths per day
- B. Cleanse the genitalia twice a day with soap and water
- C. Spray warm water over genitalia after urination
- D. Apply heat or cold to lesions as desired
Correct Answer: A
Rationale: Suggest 3 to 4 warm sitz baths per day. Frequent sitz baths may soothe the area and reduce inflammation, addressing the client's symptoms effectively.