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Three days after surgery, Mark notices that the wound site is more painful now than it was the day before. When you inspect the surgical site you are looking for redness or inflammation. Other indicators of infection would include:
- A. Elevated RBC and elevated respiratory rate.
- B. Elevated WBC and elevated temperature.
- C. Elevated erythrocyte sedimentation rate and decreased pulse.
- D. Decreased platelets and decreased blood pressure.
Correct Answer: B
Rationale: Elevated white blood cell (WBC) count and fever are classic signs of infection. These indicators suggest the body is mounting an immune response to a potential pathogen.
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Following a bone marrow transplant, the patient has an increased risk for
- A. Bleeding.
- B. Infection.
- C. Clot formation.
- D. Nausea and vomiting.
Correct Answer: B
Rationale: Immunosuppression increases the risk of infection post-transplant.
What action should the nurse include in teaching Mr. Ross about skin care of the irradiated area?
- A. Applying ointment or lotion to the skin
- B. Washing the area with soap and water
- C. Keeping the area dry and open to air
- D. Massaging the area and exposing it to sunlight
Correct Answer: C
Rationale: Protecting the skin from irritation and moisture promotes healing.
What are the responsibilities of a circulating nurse?
- A. Obtaining and opening wrapped sterile equipment.
- B. Preparing sutures.
- C. Handing instruments to the surgeon and assistants.
- D. Assisting with putting the client to sleep.
Correct Answer: A
Rationale: The correct answer is A because the circulating nurse ensures all necessary sterile equipment is available and prepared.
When selecting audiovisual and written materials as teaching strategies, what is important for the nurse to do?
- A. Provide the patient with these materials before the planned learning experience.
- B. Ensure that the materials include all the information the patient will need to learn.
- C. Review the materials before use for accuracy and appropriateness to learning needs and goals.
- D. Assess the patient’s auditory and visual ability because these functions are necessary for these strategies to be effective.
Correct Answer: C
Rationale: The correct answer is 'Review the materials before use for accuracy and appropriateness to learning needs and goals.' Ensuring the materials are accurate and appropriate is critical to effective teaching. Providing materials beforehand or ensuring they cover all needed information may not always be feasible or necessary.
What aspect of Mr. Ross’s health history is most indicative of cancer of the lung?
- A. A positive Tine test
- B. He is a vegetarian
- C. He smokes two packs of cigarettes a day
- D. He last visited a physician 2 years ago
Correct Answer: C
Rationale: Smoking is the strongest risk factor for lung cancer.