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The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what potential complications?
- A. Vertebral fracture
- B. Hematoma at the surgical site
- C. Scoliosis
- D. Renal trauma
Correct Answer: B
Rationale: The correct answer is B: Hematoma at the surgical site. This is a potential complication of cervical discectomy due to the risk of bleeding post-surgery. Hematoma can compress nearby structures and lead to increased pain and swelling.
A: Vertebral fracture is not a typical complication of cervical discectomy, as the surgery aims to relieve pressure on the spinal cord caused by a herniated disc, not to cause fractures.
C: Scoliosis is a condition characterized by abnormal lateral curvature of the spine, and it is not directly related to cervical discectomy.
D: Renal trauma is not a common complication of cervical discectomy, as the surgery focuses on the cervical spine and does not involve the kidneys or renal system.
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Fraternal twins are delivered by your Rh-negative patient. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the
- A. direct Coombs test of twin A.
- B. direct Coombs test of twin B.
- C. indirect Coombs test of the mother.
- D. transcutaneous bilirubin level for both twins.
Correct Answer: C
Rationale: The correct answer is C: indirect Coombs test of the mother. This test is crucial to determine if the mother has developed antibodies against the Rh-positive blood of twin A, which could lead to hemolytic disease of the newborn in future pregnancies. A direct Coombs test of twin A or twin B is not relevant in this scenario as it does not provide information about the mother's antibody status. Transcutaneous bilirubin levels are used to monitor jaundice in newborns and not related to Rh incompatibility. In summary, the indirect Coombs test of the mother is the most relevant test to assess the risk of hemolytic disease in future pregnancies.
Which nursing actions will the nurse implementwhen collecting a urine specimen from a patient? (Select all that apply.)
- A. Growing urine cultures for up to 12 hours
- B. Labeling all specimens with date, time, and initials
- C. Allowing the patient adequate time and privacy to void
- D. Wearing gown, gloves, and mask for all specimen handling
Correct Answer: B
Rationale: The correct answer is B: Labeling all specimens with date, time, and initials. This is important for proper identification and tracking of the specimen.
- Choice A is incorrect because urine cultures typically take longer than 12 hours to grow.
- Choice C is incorrect as privacy is important but not a specific action related to urine specimen collection.
- Choice D is incorrect as wearing gown, gloves, and mask may not be necessary for routine urine specimen collection, unless there are specific precautions needed.
A patient has returned to the floor after undergoing a transurethral resection of the prostate (TURP). The patient has a continuous bladder irrigation system in place. The patient tells you he is experiencing bladder spasms and asks what you can do to relieve his discomfort. What is the most appropriate nursing action to relieve the discomfort of the patient?
- A. Apply a cold compress to the pubic area.
- B. Notify the urologist promptly.
- C. Irrigate the catheter with 30 to 50 mL of normal saline as ordered.
- D. Administer a smooth-muscle relaxant as ordered.
Correct Answer: D
Rationale: Rationale: Administering a smooth-muscle relaxant is the most appropriate nursing action to relieve bladder spasms post-TURP. The smooth-muscle relaxant helps relax the bladder muscles, reducing spasms and discomfort. Applying a cold compress (choice A) may provide temporary relief but won't address the underlying cause. Notifying the urologist (choice B) is important but not the immediate action for relieving spasms. Irrigating the catheter with normal saline (choice C) may not effectively address the spasms. Administering a smooth-muscle relaxant is the best choice for prompt relief.
A nurse is teaching the staff about health carereimbursement. Which information should the nurse include in the teaching session?
- A. Home health, long-term care, and hospital nurses’ documentation can affect reimbursement for health care.
- B. A clinical information system must be installed by 2014 to obtain health care reimbursement.
- C. A “near miss” helps determine reimbursement issues for health care.
- D. HIPAA is the basis for establishing reimbursement for health care.
Correct Answer: A
Rationale: The correct answer is A because documentation by nurses in various settings like home health, long-term care, and hospitals impacts reimbursement. Proper documentation ensures services provided are accurately reflected, influencing reimbursement. Choice B is incorrect as it refers to Meaningful Use requirements for EHRs, not reimbursement. Choice C is incorrect as a "near miss" relates to patient safety, not reimbursement. Choice D is incorrect because HIPAA focuses on privacy and security of patient information, not reimbursement.
The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, “How much fat should I have? I guess the less fat, the better.” Which information will the nurse include in the teaching session?
- A. Cholesterol intake needs to be less than 300 mg/day.
- B. Fats have no significance in health and the incidence of disease.
- C. All fats come from external sources so this can be easily controlled.
- D. Deficiencies occur when fat intake falls below 10% of daily nutrition.
Correct Answer: D
Rationale: The correct answer is D: Deficiencies occur when fat intake falls below 10% of daily nutrition.
Rationale:
1. Fat is essential for absorption of fat-soluble vitamins (A, D, E, K) and for maintaining healthy cell membranes.
2. Fat provides essential fatty acids (omega-3, omega-6) crucial for brain function and inflammation regulation.
3. Adequate fat intake prevents deficiencies like dry skin, poor wound healing, and hormonal imbalances.
4. A low-fat diet should still include at least 10% of daily nutrition from healthy fats for optimal health.
Summary:
A: Cholesterol intake is important but not the primary focus for a low-fat diet.
B: Fats are significant for health, and extreme low-fat diets can lead to deficiencies.
C: While some fats are from external sources, the body needs a minimum amount for proper functioning.