Nokea
The patient is dangling at the bedside and states, “Oh, my stomach is tearing open.” Which of the following actions should the nurse immediately take when dehiscence occurs?
- A. Have patient sit upright in a chair.
- B. Have patient lie down.
- C. Slow IV fluids.
- D. Obtain a sterile suture set.
Correct Answer: B
Rationale: The correct answer is B: Have patient lie down. When a patient experiences dehiscence (surgical wound separation), lying down helps reduce tension on the wound, minimizing the risk of further tearing. This position also allows the nurse to assess the wound properly. Choice A is incorrect because sitting upright can increase intra-abdominal pressure, worsening the dehiscence. Choice C is incorrect as slowing IV fluids is not a priority in managing dehiscence. Choice D is incorrect because obtaining a sterile suture set should only be done by a healthcare provider and is not the immediate action needed for dehiscence.
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The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: The correct answer is C because respiratory rate is an observable and measurable data point, making it objective. Objective data is factual and observable, such as vital signs. Choices A, B, and D are subjective data as they rely on the patient's perception or interpretation, which can be influenced by various factors and may not always be accurate or reliable. In this case, the nurse can directly measure and document the patient's respiratory rate, making it an objective piece of information.
The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
- A. Administer the acetaminophen.
- B. Notify the health care provider to obtain a verbal order.
- C. Direct the nursing assistive personnel to give the acetaminophen.
- D. Perform a pain assessment only after administering the acetaminophen.
Correct Answer: A
Rationale: The correct answer is A: Administer the acetaminophen. The rationale is as follows:
1. The patient has a standing order for acetaminjson for headache relief.
2. The nurse has assessed that the patient needs headache relief and has not had the medication in the past 4 hours.
3. Administering the acetaminophen aligns with the prescribed treatment plan and the patient's needs.
Summary:
- Option B is incorrect because obtaining a verbal order is not necessary when there is a standing order.
- Option C is incorrect as nursing assistive personnel should not administer medications without direct supervision.
- Option D is incorrect as pain assessment should precede medication administration to ensure appropriateness.
Following hypophysectomy, patients require extensive teaching regarding this major alteration in their lifestyle
- A. Abnormal distribution of body hair
- B. Lifetime dependency on hormone replacement
- C. The need to drink many fluids to replace those lost
- D. The need to undergo repeat surgical procedures
Correct Answer: B
Rationale: The correct answer is B (Lifetime dependency on hormone replacement) because after hypophysectomy (removal of the pituitary gland), patients will no longer produce essential hormones like growth hormone, thyroid-stimulating hormone, etc. Therefore, they will require lifelong hormone replacement therapy to maintain normal bodily functions.
A: Abnormal distribution of body hair is not directly related to hypophysectomy.
C: While fluid intake may be important post-surgery, it is not the primary focus of teaching.
D: There is typically no need for repeat surgical procedures after a hypophysectomy, as it is a one-time surgery to address specific issues.
In summary, choice B is correct as it directly addresses the long-term implications of the surgery on hormone production and the need for replacement therapy, while the other choices are not directly relevant to the post-operative care of hypophysectomy patients.
What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?
- A. Fr. 5
- B. Fr. 12
- C. Fr. 10
- D. Fr. 18
Correct Answer: A
Rationale: The correct size of suction catheter for James would be Fr. 5. The selection of suction catheter size is based on the patient's height and weight, as well as the secretions to be cleared. A Fr. 5 catheter is appropriate for an average adult like James, as it balances between being too small or too large. Fr. 12 and Fr. 18 are too large for his size and could cause trauma, while Fr. 10 is slightly larger than needed, increasing the risk of mucosal damage. Therefore, Fr. 5 is the most suitable choice for James.
A 70-year old male diagnosed with BPH (benign prostatic hyperplasia) asks the nurse about his disease. The best response would be:
- A. “It an be caused by chronic infection of the urinary tract.”
- B. “It was caused by your chronic cigarette smoking.”
- C. “As you age, hormonal imbalances are the more likey cause of your disease.”
- D. “Chronic obstruction of the bladder due to stone can cause BPH.”
Correct Answer: C
Rationale: The correct answer is C. Hormonal imbalances are the primary cause of BPH in aging males. As men age, testosterone levels decrease and estrogen levels may increase relative to testosterone, leading to prostate gland growth. This is why hormonal imbalances are more likely the cause of BPH in older males.
Explanation of other choices:
A: Chronic infection of the urinary tract does not directly cause BPH, although it can lead to similar symptoms such as urinary frequency and urgency.
B: Chronic cigarette smoking is not a direct cause of BPH, although it can contribute to overall prostate health and exacerbate symptoms.
D: Chronic obstruction of the bladder due to stone is a separate condition from BPH, although it can cause similar urinary symptoms.