Nokea
The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?
- A. Clamp the Penrose drain.
- B. Change the dressing as prescribed.
- C. Notify the healthcare provider (HCP).
- D. Remove and replace the perineal packing.
Correct Answer: B
Rationale: In this scenario, the appropriate nursing intervention for serosanguineous drainage from the wound is to change the dressing as prescribed. This helps in maintaining wound cleanliness, preventing infection, and promoting proper wound healing. Clamping the Penrose drain (Choice A) is not indicated as the drainage is from the wound itself, not the drain. Notifying the healthcare provider (Choice C) may be necessary if there are signs of infection or other concerning issues, but changing the dressing should be done first. Removing and replacing the perineal packing (Choice D) is not the priority in this situation unless specifically prescribed by the healthcare provider after assessing the wound.
You may also like to solve these questions
What is a characteristic of normal cells?
- A. They have no functions
- B. They have a larger nucleus
- C. They undergo apoptosis
- D. They have a dark-colored nucleus
Correct Answer: C
Rationale: The correct answer is that normal cells undergo apoptosis, which is a programmed cell death process essential for maintaining tissue homeostasis. Choice A is incorrect as normal cells do have specific functions. Choice B is incorrect as the size of the nucleus may vary but is not a defining characteristic of normal cells. Choice D is incorrect as the color of the nucleus is not a standard characteristic of normal cells.
The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign of this oncological emergency?
- A. Headache
- B. Dysphagia
- C. Constipation
- D. Electrocardiographic changes
Correct Answer: D
Rationale: The correct answer is D, Electrocardiographic changes. In clients with metastatic prostate cancer, hypercalcemia can lead to various signs and symptoms. Electrocardiographic changes are considered a late sign of hypercalcemia, indicating severe electrolyte imbalance. Headache (choice A), dysphagia (choice B), and constipation (choice C) are earlier signs of hypercalcemia and may precede the development of more severe symptoms like electrocardiographic changes.
Nurse Jane is providing care for a client with superior vena cava syndrome. Which of the following interventions would be the priority?
- A. Elevate the head of the bed
- B. Administer steroids as prescribed
- C. Provide supplemental oxygen
- D. Administer diuretics as prescribed
Correct Answer: A
Rationale: The correct answer is to elevate the head of the bed. Elevating the head of the bed can help reduce the pressure on the superior vena cava, improve venous return, and facilitate breathing in clients with superior vena cava syndrome. Administering steroids (Choice B) may be necessary in some cases, but it is not the priority in the immediate care of a client with superior vena cava syndrome. Providing supplemental oxygen (Choice C) may help improve oxygenation but does not directly address the underlying issue of venous congestion. Administering diuretics (Choice D) may be contraindicated as it can further decrease preload and worsen the condition in superior vena cava syndrome.
A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best?
- A. Call the client at home the next day to review teaching.
- B. Give the client information about a cancer support group.
- C. Provide all the preoperative instructions in writing.
- D. Reassure the client that surgery will be over soon.
Correct Answer: A
Rationale: Clients are often overwhelmed by a sudden cancer diagnosis; therefore, it is best for the nurse to call the client at home the next day to review teaching. This approach allows the client time to process the information before the surgery. Choice B may be beneficial but is not the priority at this time. Providing written instructions (Choice C) is helpful but does not offer the personalized interaction needed. Reassuring the client (Choice D) is important but does not address the educational aspect of preoperative preparation.
While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?
- A. Stopping the administration of the drug immediately
- B. Notifying the patient's physician
- C. Continuing the infusion but decreasing the rate
- D. Applying a warm compress to the infusion site
Correct Answer: A
Rationale: The correct action for the nurse to take when observing swelling and pain at the IV site during the administration of doxorubicin hydrochloride is to stop the administration of the drug immediately. Doxorubicin hydrochloride can cause severe tissue damage, so discontinuing the infusion is crucial to prevent further harm to the patient. Notifying the physician is important, but it should not take precedence over stopping the drug. Continuing the infusion, even at a decreased rate, can exacerbate tissue damage. Applying a warm compress is not appropriate in this situation and may worsen the tissue injury caused by the drug.