What statement indicates Mr. Singer understands his condition after viewing a filmstrip on rehabilitation?
- A. ‘I will be able to continue my swimming as usual.’
- B. ‘I will regain some degree of my sense of smell and taste.’
- C. ‘I will not be able to bowl any more.’
- D. ‘I will have to give up my tub bath.’
Correct Answer: B
Rationale: Partial recovery of senses is possible after laryngectomy.
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Until Mr. Jones’ diagnosis is confirmed, what should be a priority?
- A. Encouraging rest
- B. Monitoring intake and output
- C. Preventing spread of infection to others
- D. Providing attractive meals
Correct Answer: C
Rationale: The correct answer is C: Preventing spread of infection to others. This is the priority because until Mr. Jones' diagnosis is confirmed, it is crucial to prevent potential transmission of any infectious diseases to others. Encouraging rest (choice A) and providing attractive meals (choice D) are important for overall well-being but not as critical as preventing the spread of infection. Monitoring intake and output (choice B) is important for assessing Mr. Jones' health status but does not directly address the potential risk of infecting others. Therefore, choice C is the most immediate priority to ensure the safety of others.
A 56-year-old patient comes to the walk-in clinic for scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history for colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis?
- A. Diarrhea/Constipation related to altered bowel patterns.
- B. Knowledge Deficit related to disease process and diagnostic procedure.
- C. Risk for Fluid Volume Deficit related to rectal bleeding and diarrhea.
- D. Anxiety related to unknown outcomes and perceived threats to body integrity.
Correct Answer: D
Rationale: The patient's anger and threat to leave indicate significant anxiety, which must be addressed before proceeding with education or further assessment.
A client is scheduled for a coronary artery bypass graft (CABG) in the morning using a saphenous vein. The physician does not use the internal mammary artery for the bypass graft, because the internal mammary artery:
- A. takes more time to remove.
- B. has a greater risk of becoming reoccluded.
- C. is smaller in diameter.
- D. has too many valves.
Correct Answer: A
Rationale: Many physicians do not use the internal mammary artery because it is time consuming. Removing the internal mammary artery does not pose a greater risk of reocclusion. In fact, it may stay patent longer. The internal mammary artery is larger in diameter than the saphenous vein. The internal mammary artery does not have too many valves.
Which nursing actions are completed by the scrub nurse (select all that apply)?
- A. Prepares instrument table
- B. Documents intraoperative care
- C. Remains in the sterile area of the OR
- D. Checks mechanical and electrical equipment
Correct Answer: A
Rationale: The scrub nurse manages sterile instruments and assists the surgical team within the sterile field.
To prevent a common, adverse effect of prolonged use of phenytoin sodium (Dilantin), patients taking the drug are instructed to
- A. avoid crowds and obtain an annual influenza vaccination.
- B. drink at least 2 L of fluids daily, including 8 to 10 glasses of water.
- C. eat a potassium-rich, low-sodium diet.
- D. practice good dental hygiene and report gum swelling or bleeding.
Correct Answer: D
Rationale: Phenytoin can cause gum hyperplasia, so good dental hygiene is essential.