Nokea
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.
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A client in the late stage of inhalation anthrax requires a plan of care. What is appropriate to include in the plan of care?
- A. Provide respiratory support.
- B. Place the client in droplet isolation.
- C. Administer antihypertensive medications.
- D. Monitor ascites.
Correct Answer: A
Rationale: Step 1: Inhalation anthrax causes severe respiratory distress.
Step 2: Providing respiratory support helps maintain oxygenation.
Step 3: Oxygen therapy or mechanical ventilation may be needed.
Step 4: This choice directly addresses the critical needs of the client.
Summary:
- B: Droplet isolation is not needed as anthrax is not transmitted person-to-person.
- C: Antihypertensive medications are irrelevant to inhalation anthrax treatment.
- D: Ascites monitoring is not a priority in late-stage inhalation anthrax.
What is an example of a pertinent negative finding during a physical examination?
- A. Chest pain that does not radiate to the arm
- B. Elevated blood pressure in a patient with hypertension
- C. Pupils that are equal and react to light and accommodation
- D. Clear and full lung sounds in a patient with chronic bronchitis
Correct Answer: A
Rationale: The correct answer is 'Chest pain that does not radiate to the arm.' Pertinent negatives highlight clinically significant absences of expected findings, helping rule out certain conditions like cardiac ischemia.
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 has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?
- A. Continue to monitor the client.
- B. Immediately notify the healthcare provider.
- C. Reposition the client to the left side.
- D. Clamp the chest tube near the water seal.
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client. When the water seal chamber rises with client inspiration, it indicates normal functioning of the chest tube system, allowing air to exit the pleural space. Monitoring ensures proper chest tube function. Option B is incorrect because there is no indication of immediate need for healthcare provider notification. Option C is unnecessary as repositioning won't address the issue. Option D is incorrect and dangerous as clamping the chest tube can lead to tension pneumothorax.
Mary presents difficulty breathing, fatigue, orthopnea, and palpitation, and is diagnosed as having aortic insufficiency. After undergoing aortic valve repair, what medication would you expect her physician to prescribe?
- A. Ativan.
- B. Haldol.
- C. Heparin.
- D. Thorazine.
Correct Answer: C
Rationale: Anticoagulation is often required post-valve repair to prevent clot formation.