Nokea
The nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair. Which of the following assessment findings is most important to communicate to the health care provider?
- A. Absence of flatus
- B. Loose, bloody stools
- C. Hypotonic bowel sounds
- D. Abdominal pain with palpation
Correct Answer: B
Rationale: Loose, bloody stools at this time may indicate intestinal ischemia or infarction and should be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.
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The health care provider prescribes an infusion of argatroban and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which of the following actions should the nurse include in the plan of care?
- A. Avoid giving any IM medications to prevent localized bleeding.
- B. Discontinue the infusion for PTT values greater than 50 seconds.
- C. Monitor posterior tibial and dorsalis pedis pulses with the Doppler.
- D. Have vitamin K available in case reversal of the argatroban is needed.
Correct Answer: A
Rationale: IM injections are avoided in patients receiving anticoagulation. A PTT of 50 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.
The nurse is caring for a patient with chronic atrial fibrillation who develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. Which of the following actions should the nurse implement first?
- A. Elevate the left leg on a pillow.
- B. Apply an elastic wrap to the leg.
- C. Assist the patient in gently exercising the leg.
- D. Notify the health care provider.
Correct Answer: D
Rationale: The patient's history and clinical manifestations are consistent with acute arterial occlusion. Clinical manifestations of acute arterial ischemia include the 'six Ps': pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia (adaptation of the limb to the environmental temperature most often cool). Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the nurse should immediately notify the health care provider. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.
Which of the following responses by a patient who is on anticoagulant therapy indicates the need for further teaching?
- A. I can still have a glass of wine with my dinner.
- B. For pain relief I will take ibuprofen.
- C. I take my pills at two o'clock every day.
- D. I will use an electric razor for shaving.
Correct Answer: B
Rationale: Patients on anticoagulant therapy should avoid all NSAIDs; therefore ibuprofen should not be taken for pain relief. It is acceptable to have an alcohol intake of a glass of wine daily. It is important that medications be taken at the same time every day. Patients are taught to avoid the use of a straight razor.
Which of the following patients in the emergency department should the nurse assess first?
- A. 62-year-old who has gangrenous ulcers on both feet
- B. 50-year-old who is complaining of 'tearing' chest pain.
- C. 45-year-old who is taking anticoagulants and has bloody stools
- D. 36-year-old who has right calf tenderness, redness, and swelling
Correct Answer: B
Rationale: The patient's presentation is consistent with aortic dissection, which will require rapid intervention. The other patients do not need urgent interventions.
The nurse is providing teaching to a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition. Which of the following behaviours by the patient indicates that the teaching has been effective?
- A. The patient avoids the use of Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).
- B. The patient exercises indoors during the winter months.
- C. The patient places the hands in hot water when they turn pale.
- D. The patient takes pseudoephedrine for cold symptoms.
Correct Answer: B
Rationale: Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm, rather than hot, water to warm the hands. Pseudoephedrine, a vasoconstrictor, should be avoided. There is no reason to avoid taking Aspirin and NSAIDs with Raynaud's phenomenon.