Nokea
The surgical nurse is admitting a patient from postanesthetic recovery following the patients below-the-knee amputation. The nurse recognizes the patients high risk for postoperative hemorrhage and should keep which of the following at the bedside?
- A. A tourniquet
- B. A syringe preloaded with vitamin K
- C. A unit of packed red blood cells, placed on ice
- D. A dose of protamine sulfate
Correct Answer: A
Rationale: Immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the patients bedside so that, if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. PRBCs cannot be kept at the bedside. Vitamin K and protamine sulfate are antidotes to warfarin and heparin, but are not administered to treat active postsurgical bleeding.
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A nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage which of the following?
- A. Apply heat for the first 24 to 48 hours after the injury.
- B. Maintain the ankle in a dependent position.
- C. Exercise hourly by performing rotation exercises of the ankle.
- D. Keep an elastic compression bandage on the ankle.
Correct Answer: D
Rationale: Treatment of a sprain consists of resting and elevating the affected part, applying cold, and using a compression bandage. After the acute inflammatory stage (usually 24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises would likely be painful.
A patient has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurses initial postsurgical assessment were unremarkable but the patient has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurses initial action?
- A. Apply a tourniquet.
- B. Elevate the residual limb.
- C. Apply sterile gauze.
- D. Call the surgeon.
Correct Answer: A
Rationale: The nurse should apply a tourniquet in the event of postsurgical hemorrhage. Elevating the limb and applying sterile gauze are likely insufficient to stop the hemorrhage. The nurse should attempt to control the immediate bleeding before contacting the surgeon.
A 20 year-old is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The patient has an open fracture of his tibia. The wound is highly contaminated and there is extensive soft-tissue damage. How would this patients fracture likely be graded?
- A. Grade I
- B. Grade II
- C. Grade III
- D. Grade IV
Correct Answer: C
Rationale: Open fractures are graded according to the following criteria. Grade I is a clean wound less than 1 cm long. Grade II is a larger wound without extensive soft-tissue damage. Grade III is highly contaminated, has extensive soft-tissue damage, and is the most severe. There is no grade IV fracture.
A patient who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team?
- A. Maximize the efficiency of care
- B. Ensure that the patients health care is holistic
- C. Facilitate the patients adjustment to a new body image
- D. Promote the patients highest possible level of function
Correct Answer: D
Rationale: The multidisciplinary rehabilitation team helps the patient achieve the highest possible level of function and participation in life activities. The team is not primarily motivated by efficiency, the need for holistic care, or the need to foster the patients body image, despite the fact that each of these are valid goals.
A patient with a simple arm is receiving discharge education from the nurse. What would the nurse instruct the patient to do?
- A. Elevate the affected extremity to shoulder level when at rest.
- B. Engage in exercises that strengthen the unaffected muscles.
- C. Apply topical anesthetics to accessible skin surfaces as needed.
- D. Avoid using analgesics so that further damage is not masked.
Correct Answer: B
Rationale: The nurse will encourage the patient to engage in exercises that strengthen the unaffected muscles. Comfort measures may include appropriate use of analgesics and elevation of the affected extremity to the heart level. Topical anesthetics are not typically used.