Nokea
Which nursing action should be included in the plan of care for a client returning to the surgical unit following a left modified radical mastectomy with dissection of axillary lymph nodes?
- A. Obtain permanent breast prosthesis before the patient is discharged from the hospital
- B. Teach the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes
- C. Place a pink bracelet on the client warning against venipunctures or blood pressures in the left arm
- D. Insist that the patient examine the surgical incision when the initial dressings are removed
Correct Answer: C
Rationale: Mastectomy with axillary dissection risks lymphedema a pink bracelet flags the left arm, barring venipuncture or BP cuffs to prevent swelling, a priority in post-op care. Prosthesis comes later, post-healing. PCA teaching avoids rigid timing PRN's key. Forcing incision checks risks distress, not healing. Nurses lock in this bracelet, safeguarding lymph flow, a must-do in this surgical aftermath to dodge chronic arm woes.
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Rehabilitation utilises two types of rehabilitation interventions. The goal of the intervention support is to
- A. Maintaining existing abilities
- B. Restoring function
- C. Preventing deterioration and further disability
- D. Maintaining existing abilities while preventing new or further disabilities
Correct Answer: D
Rationale: Rehab's dual play hold steady, fend off worse blends maintenance and prevention, a chronic balance. Nurses aim here, a full guard.
An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?
- A. Apply an ice pack or heating pad PRN to relieve pain and pruritis
- B. Avoid skin contact with water whenever possible
- C. Apply phototherapy PRN
- D. Avoid rubbing or scratching the affected area
Correct Answer: D
Rationale: Radiation erythema's tender rubbing or scratching tears it open, risking infection. Ice or heat burns it worse; water's fine for gentle cleaning, not avoidance. Phototherapy's for jaundice, not this. Nurses push hands off' to protect radiated skin, a staple in oncology to heal without added damage.
A 58 year old woman is known to have diabetes mellitus for 20 years. Her glycaemic control has deteriorated over the last three years. She is currently on Insulin and Metformin. Her serum creatinine is 140 μmol/L. Urinalysis performed over the last six months showed persistent proteinuria 1+. What should be the MOST appropriate target blood pressure for this lady?
- A. <125/75 mmHg
- B. <130/85 mmHg
- C. <130/80 mmHg
- D. <120/70 mmHg
Correct Answer: C
Rationale: Diabetes 20 years, proteinuria, creatinine 140 CKD stage 3 needs BP under 130/80 to shield kidneys, per guidelines. Tighter risks perfusion; looser misses protection. Insulin and metformin tag along, but BP's the chronic guard nurses enforce here.
Atherosclerosis is a chronic inflammatory response of the vascular walls to endothelial injury. During the progression of these lesions, interaction occurs between various factors. Question: Which cells do NOT play a role in this process?
- A. Epithelial cells
- B. Lipoproteins
- C. Macrophages
- D. T-lymphocytes
Correct Answer: A
Rationale: Atherosclerosis macrophages, T-cells, lipoproteins clog, not epithelial outsiders. Nurses track this, a chronic vessel crew.
The nurse is arriving at the beginning of her shift and has taken report on four clients on a medical surgical unit. Which client should the nurse see first?
- A. A Client with pyelonephritis with nausea and vomiting
- B. A client with chronic obstructive pulmonary disease with an oxygen saturation of $90 \%$ on room air
- C. A client post vaginoplasty with bright red blood and clots in her catheter
- D. A client post-total abdominal hysterectomy with 9/10 pain
Correct Answer: C
Rationale: Bright red blood and clots post-vaginoplasty scream hemorrhage ABCs prioritize circulation, needing instant check for shock or transfusion. Pyelonephritis nags, COPD's stable at 90\%, pain's urgent but not bleeding. Nurses hit bleeding first, a life-line call in this post-op rush.