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When performing tracheostomy care, which intervention should the nurse implement?
- A. Use aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply suction when inserting the catheter.
Correct Answer: C
Rationale: The correct answer is C: Secure new tracheostomy ties before removing old ones. This is essential to ensure the patient's airway remains stable and secure during the procedure. By securing the new ties first, the tracheostomy tube will not accidentally dislodge or become displaced.
A: Using aseptic technique is important but not the immediate priority in this situation.
B: Cleaning the inner cannula is a routine part of tracheostomy care but not the primary intervention during tie change.
D: Applying suction when inserting the catheter is incorrect as suctioning should be performed after securing the new ties to maintain airway patency.
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Which member of the surgical team does not scrub in the OR?
- A. The surgeon.
- B. The circulating nurse.
- C. The scrub nurse or surgical tech.
- D. The holding area nurse.
Correct Answer: B
Rationale: The circulating nurse remains outside the sterile field to assist with supplies.
A 44-year-old male client had abdominal surgery this morning. The nurse noticed a small amount of bloody drainage on the client's surgical dressing. This type of drainage is:
- A. serosanguineous.
- B. purulent.
- C. sanguineous.
- D. catarrhal.
Correct Answer: C
Rationale: Drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Purulent drainage usually indicates infection. This drainage should not be seen initially from a surgical incision. An incision with a Penrose drain may be expected to have a moderate amount of serosanguineous drainage in the first 24 hours, but in general drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.
A client was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer?
- A. Ciprofloxacin
- B. Fluconazole
- C. Tobramycin
- D. Vancomycin
Correct Answer: A
Rationale: The correct answer is A: Ciprofloxacin. Anthrax is caused by the bacterium Bacillus anthracis, and ciprofloxacin is the recommended antibiotic for treating anthrax due to its effectiveness against this specific bacterium. Ciprofloxacin works by inhibiting bacterial DNA replication, thus stopping the growth and spread of the anthrax bacteria.
The other choices are incorrect because:
B: Fluconazole is an antifungal medication and is not effective against bacterial infections like anthrax.
C: Tobramycin is an antibiotic primarily used to treat bacterial infections in the eyes, ears, and skin, but it is not the first-line treatment for anthrax.
D: Vancomycin is an antibiotic used to treat certain bacterial infections, but it is not the preferred choice for anthrax treatment.
Which of the following would you include as risk factors for the development of skin cancer when assessing the integumentary system?
- A. Advancing age
- B. Positive family history
- C. Dark pigmentation
- D. White collar job
Correct Answer: B
Rationale: Advancing age by itself is not a risk factor. If that person has been exposed to a lot of sun there may be increased risk, but that information is not given here. There is a known genetic risk, with some cancers being seen to be present in families with low risk factors. Those with dark pigmentation develop skin cancer, but at a lower rate than those with low amounts of pigmentation. White collar jobs, which occur in offices and inside buildings, are a low risk for skin cancer.
A 25-year-old client is admitted for a tonsillectomy and informs the nurse of having had episodes of muscle cramps, weakness, and an unexplained temperature elevation. Many years ago, the client's father died shortly after surgery subsequent to developing a high fever. The surgeon has ordered dantrolene sodium (Dantrium) prophylactically prior to the tonsillectomy to reduce the risk of:
- A. a postoperative infection.
- B. malignant hyperthermia.
- C. neuroleptic malignant syndrome.
- D. a postoperative fever.
Correct Answer: B
Rationale: Dantrolene sodium (Dantrium) is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection. Dantrolene sodium (Dantrium) is indicated prophylactically for clients with malignant hyperthermia or with a family history of the disorder. The mortality rate for malignant hyperthermia is high. Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is not related to malignant hyperthermia. Dantrolene sodium (Dantrium) is a peripheral skeletal muscle relaxant and would have no effect on a postoperative fever.