Nokea
What a patient has bleeding after surgery the PACU nurse, expects which color if coming from the arterial source?
- A. Darkly-colored, blood flows fast.
- B. Bright red and spurts with the heartbeat.
- C. slow, dark-colored, generally ooze.
- D. Pinkish colored- slowly flowing.
Correct Answer: B
Rationale: The correct answer is B: Bright red and spurts with the heartbeat. This type of bleeding indicates arterial bleeding, which is oxygen-rich blood coming directly from the arteries. Arterial bleeding is bright red in color due to the high oxygen content and spurts with the heartbeat as it is under higher pressure. This rapid spurting is characteristic of arterial bleeding and requires immediate attention to control the bleeding source.
Choices A, C, and D are incorrect because they describe characteristics of venous bleeding, not arterial bleeding. Venous bleeding is dark in color, flows slowly, and generally oozes as it is oxygen-depleted blood returning to the heart. Therefore, the correct answer is B based on the specific characteristics of arterial bleeding.
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During a surgical procedure, the nurse notices a sudden decrease in the patient's oxygen saturation on the monitor. What immediate action should the nurse take?
- A. Inform the surgeon and anesthesiologist
- B. Increase the flow rate of oxygen
- C. Check the endotracheal tube placement
- D. Assess the patient's respiratory status
Correct Answer: A
Rationale: The correct immediate action is to inform the surgeon and anesthesiologist (Choice A) because a sudden decrease in oxygen saturation during surgery is a critical situation that requires prompt attention from the entire surgical team. The surgeon and anesthesiologist need to be made aware of the situation so that they can assess the patient's condition and make any necessary adjustments to the surgical procedure or anesthesia delivery. Increasing the flow rate of oxygen (Choice B) may help temporarily but does not address the underlying cause of the oxygen desaturation. Checking the endotracheal tube placement (Choice C) is important but may not be the immediate priority in this critical situation. Assessing the patient's respiratory status (Choice D) is important but should be done after informing the surgeon and anesthesiologist to ensure coordinated and timely interventions.
Which of the following interventions is recommended for managing a patient with suspected pelvic inflammatory disease (PID)?
- A. Empiric antibiotic therapy directed against common pathogens.
- B. Surgical exploration and drainage of pelvic abscesses.
- C. Hormonal therapy to suppress ovarian function.
- D. Symptomatic treatment with nonsteroidal anti-inflammatory drugs (NSAIDs).
Correct Answer: A
Rationale: The correct answer is A: Empiric antibiotic therapy directed against common pathogens. This is recommended for managing PID because it helps treat the infection and prevent complications. Antibiotics target the underlying bacterial infection causing PID. Surgical exploration (B) is not the initial treatment for PID. Hormonal therapy (C) is not indicated for PID management. Symptomatic treatment with NSAIDs (D) can help with pain but does not address the infection itself.
A postpartum client presents with severe abdominal pain, nausea, and vomiting. Which nursing action is most appropriate?
- A. Administering antiemetic medication as ordered
- B. Encouraging the client to drink clear fluids
- C. Assessing for signs of peritonitis or surgical abdomen
- D. Providing a heating pad to alleviate abdominal discomfort
Correct Answer: C
Rationale: In a postpartum client who presents with severe abdominal pain, nausea, and vomiting, it is crucial to assess for signs of peritonitis or surgical abdomen. These signs may include rebound tenderness, guarding, rigidity, and fever. Peritonitis is a serious condition that may require immediate surgical intervention. Administering antiemetic medication, encouraging clear fluids, or providing a heating pad may not address the underlying cause of the symptoms and delay appropriate treatment. Assessing for signs of peritonitis or surgical abdomen is crucial for prompt identification and management of the client's condition.
Which of the following clinical manifestations is most indicative of acute respiratory distress syndrome (ARDS)?
- A. Hypocapnia with respiratory alkalosis
- B. Bradypnea with metabolic acidosis
- C. Tachypnea with hypoxemia refractory to supplemental oxygen
- D. Hypercapnia with hyperkalemia
Correct Answer: C
Rationale: Rationale:
- ARDS is characterized by severe hypoxemia and respiratory distress.
- Tachypnea is a hallmark sign of ARDS due to the body's compensatory mechanism to increase oxygenation.
- Hypoxemia refractory to supplemental oxygen signifies the inability to improve oxygen levels despite intervention.
- Choices A, B, and D do not align with typical manifestations of ARDS, as they do not directly reflect severe hypoxemia or respiratory distress.
A postpartum client who delivered via cesarean section expresses discomfort when ambulating and performing activities of daily living. What nursing intervention should be prioritized to promote optimal recovery?
- A. Encouraging early ambulation and progressive activity as tolerated
- B. Administering oral analgesics on a fixed schedule around the clock
- C. Restricting movement to prevent disruption of the incision site
- D. Applying heat packs to the incision site for pain relief
Correct Answer: A
Rationale: Encouraging early ambulation and progressive activity as tolerated is the most appropriate nursing intervention to promote optimal recovery for a postpartum client who delivered via cesarean section. Early ambulation helps prevent complications such as blood clots, pneumonia, and constipation. It also promotes circulation and facilitates healing by reducing the risk of postoperative complications. Progressive activity helps the client regain strength, mobility, and independence, which are essential for a speedy recovery. Restoring normal movement will also help decrease discomfort and improve the client's overall well-being. In contrast, restricting movement may lead to complications and delayed recovery. Administering oral analgesics as needed is important for pain management, but promoting early ambulation is essential for optimal recovery. Heat packs should not be applied to the incision site as they can increase the risk of infection and interfere with proper wound healing.