Medical-Surgical Nursing Exam 5

EXPLANATION

✔Correct answer:

None of the choices. All of the listed components - amino acids, dextrose, and trace minerals - are typically included in a TPN solution.

• Amino acids. These are necessary for protein synthesis and repair of body tissues. Therefore, they are a crucial component of TPN solutions.
• 10% dextrose. Dextrose provides the body with essential carbohydrates, which serve as a primary energy source. It is an important part of TPN.
• Trace minerals. Trace minerals such as zinc, copper, manganese, and chromium are essential for various bodily functions, including enzyme activity and metabolic processes. Therefore, they are also typically included in TPN.

EXPLANATION

✔Correct answer:

Utilize a trochanter roll alongside the patient's upper thighs. A trochanter roll, which is a rolled-up towel or special device placed along the lateral side of the patient's upper thighs, can help prevent external rotation of the legs when the patient is in a supine position. By providing support and maintaining the legs in alignment, it can help prevent musculoskeletal complications such as contractures.

✘Incorrect answer options:

Position a pillow directly under the patient's knees. While this position can help relieve lower back discomfort, it doesn't prevent external rotation of the legs.

Lower the patient's legs so that they are below the hips. Lowering the patient's legs below the hips doesn't prevent external rotation. It's more related to preventing deep vein thrombosis by promoting venous return.

Instruct the patient to maintain their legs in an adducted position. While this instruction could theoretically help prevent external rotation, it's not practical for long periods and could lead to discomfort and other complications.

EXPLANATION

✔Correct answer:

Slight abduction. Following a femoral neck fracture, the hip is typically positioned in slight abduction to reduce the risk of hip dislocation, particularly after a hip arthroplasty (hip replacement) surgery. This position also helps to maintain the natural alignment and function of the hip joint.

✘Incorrect answer options:

Moderate flexion. Placing the hip in moderate flexion following a femoral neck fracture or surgery can increase the risk of hip dislocation and hinder the healing process. It's important to follow the specific instructions from the healthcare provider, which usually include limiting hip flexion to 90 degrees or less.

Extension. While extension is not necessarily harmful, it is not the recommended position following a femoral neck fracture. The hip should typically be kept in a neutral position with slight abduction.

Slight adduction. Slight adduction is not recommended following a femoral neck fracture as it can increase the risk of hip dislocation. The hip should be kept in slight abduction to maintain proper alignment and joint function.

EXPLANATION

✔Correct answer:

Minimal care (Category 1). In a patient classification system, patients who require minimal therapy and less frequent observation typically fall under the "minimal care" category. These patients are generally stable and their condition is not expected to change rapidly.

✘Incorrect answer options:

Moderate care (Category 2). This category usually includes patients who require more care than those in the minimal care category. They may have more complex needs, require more frequent observation, or be at a greater risk of condition changes.

Maximum care (Category 3). This category typically includes patients who require a significant amount of care, often due to serious illness or injury. These patients typically require very frequent or constant observation and may have complex care needs.

Intensive care (Category 4). This category is for patients who are critically ill and require intensive, constant care and observation. These patients often have highly complex care needs and are at high risk of rapid condition changes.

EXPLANATION

✔Correct answer:

Impacted cerumen. Ear canal irrigation, also known as ear syringing, is commonly used to remove impacted cerumen (earwax) that can cause symptoms like pain, hearing loss, tinnitus, or vertigo. This procedure involves injecting a stream of warm water into the ear canal to loosen and wash out the cerumen.

✘Incorrect answer options:

Tympanic membrane perforation. Irrigation is contraindicated if a patient has a perforated tympanic membrane because it could lead to further injury or infection. The water could potentially enter the middle ear and lead to complications such as otitis media.

Acoustic neuroma. Acoustic neuroma is a benign tumor of the nerve that connects the ear to the brain. It's not treated with ear canal irrigation but usually requires surgery, radiation therapy, or monitoring.

Foreign body in the ear canal. Irrigation may not be the best choice for removing a foreign body from the ear canal, especially if the object is sharp or irregularly shaped, as it could potentially cause injury. It's also not recommended if the foreign body is an insect or something that can swell when wet. Typically, a healthcare provider will remove foreign bodies using specialized instruments.

EXPLANATION

✔Correct answer:

“I will use tanning booths instead of sunbathing from now on.” Tanning booths expose the skin to ultraviolet (UV) radiation, which can increase the risk of skin cancer, including basal cell carcinoma. Using a tanning booth is not a safer alternative to sunbathing, and it is not recommended, especially for those who have had skin cancer.

✘Incorrect answer options:

“I will wear a wide-brimmed hat when I am in the sun.” Wearing a wide-brimmed hat can protect the face and neck from the sun and is a recommended sun-protection measure.

“I will use sunscreen with a sun protection factor (SPF) of at least 15.” Using sunscreen with an SPF of at least 15 can help protect the skin from UV radiation. However, it's important to remember that no sunscreen can block all UV rays, and other sun-protection measures should be used as well.

“I will avoid sun exposure between 10:00 AM and 2:00 PM.” The sun's rays are strongest between 10:00 AM and 2:00 PM, so avoiding sun exposure during these hours can help reduce the risk of skin cancer.

EXPLANATION

✔Correct answer:

Intensive Care (Category 4): The patient classification system where patients need close attention and complete care in most activities and requires frequent and complex treatments and medications is called Intensive Care (Category 4).

✘Incorrect answer options:

Minimal Care (Category 1) is a patient classification system where patients require minimal assistance with activities of daily living and have stable vital signs.

Moderate Care (Category 2) is a patient classification system where patients require moderate assistance with activities of daily living and may have unstable vital signs.

Maximum Care (Category 3) is a patient classification system where patients require complete assistance with activities of daily living and may have unstable vital signs.

EXPLANATION

✔Correct answer:

“Let's discuss the available options.” This response supports the patient's autonomy and gives them the space to talk about their feelings and concerns. It also encourages shared decision-making, where the patient is an active participant in their own care.

✘Incorrect answer options:

“I recommend getting a second opinion before undergoing surgery.” This response might be helpful in some situations, but it is not the nurse's role to suggest a second opinion without a discussion about the patient's feelings and understanding about the recommended treatment.

“You should adhere to the doctor's recommendation.” While it's important to respect the physician's expertise, this response does not encourage patient autonomy or shared decision-making.

“What does your family want you to do?” While family input can be important, the primary focus should be on what the patient wants and feels comfortable with. This response might inadvertently pressure the patient to follow their family's wishes instead of their own.

EXPLANATION

✔Correct answer:

Antihypertensives. Certain antihypertensive medications, particularly those in the class of selective serotonin reuptake inhibitors (SSRIs) and beta-blockers, are known to potentially cause sexual side effects such as delayed ejaculation. This is due to the physiological effects these medications have on the body, including altering neurotransmitter levels or reducing sympathetic nervous system activity, which can impact sexual function.

✘Incorrect answer options:

Antibiotics. Antibiotics are not typically associated with delayed ejaculation. These drugs are used to treat bacterial infections and work by killing bacteria or preventing them from multiplying. While they can have side effects, sexual dysfunction is not commonly one of them.

Anticoagulants. Anticoagulants are medications used to prevent blood clots. They do not typically cause sexual side effects such as delayed ejaculation. They work by interrupting the process involved in the formation of blood clots.

Steroids. Steroids can have a variety of effects on the body, but they are not typically associated with delayed ejaculation. Steroids, particularly anabolic steroids, may cause other sexual side effects, such as reduced sperm production or shrunken testicles, primarily when misused or abused.

EXPLANATION

✔Correct answer:

90°F (32.2°C). For a tepid sponge bath, the water should be lukewarm, not cold. A temperature of 90°F (32.2°C) is generally recommended. The aim is to cool the person down gradually without causing them to shiver, which can increase their body temperature.

✘Incorrect answer options:

105°F (40.5°C). This temperature is too high for a tepid sponge bath intended to reduce fever. The purpose of the bath is to facilitate heat loss through evaporation, and water at this temperature may not be effective in reducing the body's temperature.

65°F (18.3°C). This temperature is too cold for a tepid sponge bath. Using water that is too cold can cause the person to shiver, which can increase metabolic activity and potentially raise body temperature.

120°F (48.9°C). This temperature is too high and can potentially cause burns. It is not suitable for a tepid sponge bath.

EXPLANATION

✔Correct answer:

Indifference and lack of interest in the environment. Children with undiagnosed hearing loss may seem indifferent or uninterested in their environment. This is because they may not hear sounds or conversations happening around them, making it harder for them to engage with the world. This can also lead to issues with social interactions and development.

✘Incorrect answer options:

Hyperactivity. Hearing loss does not necessarily cause hyperactivity. Hyperactivity is more commonly associated with conditions like Attention Deficit Hyperactivity Disorder (ADHD).

Hand gestures while speaking. While some children with hearing loss may use gestures or sign language, this is more common in children who have been diagnosed and taught alternative methods of communication. An undiagnosed child may not have learned these communication methods yet.

Decreased appetite. Hearing loss is not typically associated with a decreased appetite. Changes in appetite can be caused by many other factors, including illness, stress, or certain medications.

EXPLANATION

✔Correct answer:

Incapacity to cough. When an individual's airway is completely obstructed, they are unable to make any sounds, including coughing, because no air can pass through the airway. This is a medical emergency and immediate intervention is required to clear the airway and restore breathing.

✘Incorrect answer options:

Strident crowing sounds during speech attempts. These sounds, also known as stridor, typically indicate a partial obstruction of the airway, often in the larynx or trachea, not a complete obstruction.

Prolonged, deep breaths. This type of breathing pattern is not typically associated with airway obstruction. It could be seen in various conditions, such as metabolic acidosis, but not specifically indicative of an obstructed airway.

Audible wheezing upon auscultation. Wheezing, a high-pitched sound produced primarily during expiration, is often associated with narrowed airways, as seen in conditions like asthma or chronic obstructive pulmonary disease (COPD), not a complete airway obstruction.

EXPLANATION

✔Correct answer:

Moisture vapor permeable dressing. For a stage II pressure ulcer, which involves partial-thickness skin loss, a moist wound healing environment is often recommended. Moisture vapor permeable (also known as semi-permeable) dressings allow for gas exchange while preventing excessive moisture loss. They maintain a moist environment that can promote healing and are generally recommended for shallow, clean wounds like stage II pressure ulcers.

✘Incorrect answer options:

Dry gauze dressing. Dry gauze dressing is not typically recommended for a stage II pressure ulcer because it can adhere to the wound bed and cause trauma when removed. It does not provide the moist environment needed for optimal wound healing.

Wet-to-dry dressing. This type of dressing is typically used for wounds that require debridement, not for clean, shallow wounds like a stage II pressure ulcer. Wet-to-dry dressing can cause damage to healthy tissue in the wound bed when removed.

Wet gauze dressing. While a moist environment is good for wound healing, a wet dressing can lead to tissue maceration (softening and breakdown of skin due to prolonged exposure to moisture) which can delay healing and potentially cause further damage.

EXPLANATION

✔Correct answer:

Communicate with the nursing staff at the physician's office to determine what the client has been taught and her level of understanding. Communication with the nursing staff at the physician's office is crucial in this situation. This helps the nurse understand what information the client has already been provided and assess the client's understanding of the upcoming surgery. This information will guide the nurse in providing further patient education, addressing any knowledge gaps, and alleviating any concerns or anxieties the patient may have. Effective preoperative education can improve patient outcomes and satisfaction.

✘Incorrect answer options:

Entrust the postoperative nurses with patient education, as the patient may be too anxious before surgery. This answer is not optimal because preoperative education is essential in preparing a patient for surgery and reducing anxiety. Postoperative education is also necessary but may not cover all the information the patient needs to understand before the surgery.

Ensure that the post-anesthesia recovery unit nurses are aware of what to teach the patient prior to discharge. While it's important for the post-anesthesia recovery unit nurses to provide appropriate education before discharge, this doesn't address the need for preoperative education. The patient needs to be well-informed about the surgery before it happens, not just after.

Assume that the patient is already fully informed about her surgery. This is incorrect because the nurse should never assume that the patient is fully informed. Even if the physician has discussed the procedure with the patient, the nurse should still verify the patient's understanding and provide further education as necessary.

EXPLANATION

✔Correct answer:

Utilize verbal communication and observe their response. When attempting to assess a client's hearing impairment, the nurse should first attempt to communicate verbally with the client and observe their response. This direct method provides an opportunity to understand the degree of hearing impairment and the client's ability to understand spoken language.

✘Incorrect answer options:

Inquire about the client through a family member. While family members can provide valuable information about a client's hearing capabilities, it's essential to assess the client directly whenever possible. This ensures the most accurate and current information about the client's condition.

Provide the client with a written message. This can be a useful technique if the individual has severe hearing loss or if verbal communication is ineffective. However, it should not be the first method employed. Additionally, this method assumes that the client can read and understand written language, which may not always be the case.

Communicate with the client using sign language. While sign language can be an effective communication method for some individuals with hearing impairment, not all people with hearing loss know sign language. Therefore, this method should not be the initial mode of communication unless it's known that the client uses sign language.

EXPLANATION

✔Correct answer:

"It's normal to feel scared before a major surgery. What specifically are you afraid of?" This response validates the patient's feelings and encourages further dialogue about her specific fears. It is therapeutic and allows the patient to explore her feelings and concerns.

✘Incorrect answer options:

"Don't worry, you are in good hands." While it's important to reassure the patient about the competence of the healthcare team, this response dismisses the patient's fears and does not allow her to express her specific concerns.

"I know how you feel about your condition." This response is not appropriate as it assumes the nurse fully understands the patient's feelings. It's crucial not to generalize or assume the feelings of the patient.

"Let us ask your doctor about your operation." While involving the doctor in the conversation can be beneficial, this response does not directly address the patient's immediate fear or allow her to express her concerns.

EXPLANATION

✔Correct answer:

Risk for aspiration related to anesthesia. Immediately after surgery under general anesthesia, the highest priority nursing diagnosis is "Risk for aspiration related to anesthesia." General anesthesia can suppress the gag reflex and impair swallowing, which can potentially lead to aspiration. Aspiration, especially of gastric contents, can cause serious complications such as pneumonia, acute respiratory distress syndrome (ARDS), or even cardiac arrest.

✘Incorrect answer options:

Fluid volume deficit related to fluid and blood loss from surgery. Although this is an important nursing diagnosis postoperatively, it is not the highest priority immediately after general anesthesia. The patient's fluid volume status can be managed and monitored by the healthcare team through intravenous fluids and blood products if necessary.

Altered body image related to surgical incisions. Although this may be a concern for the patient, it is not a high priority immediately following surgery under general anesthesia. This issue can be addressed once the patient is stable and alert.

Pain related to the surgery. While pain is certainly a concern postoperatively, immediate post-anesthesia care prioritizes airway management and the prevention of complications such as aspiration. Once the patient is stable and awake, pain can be assessed and managed effectively.

EXPLANATION

✔Correct answer:

"Why do you drink so much?" Asking "Why do you drink so much?" can come across as judgmental and may put the client on the defensive. Nurses should aim to create a safe, non-judgmental environment that encourages open and honest communication. It's essential to use a respectful, empathetic approach when discussing sensitive topics like substance abuse.

✘Incorrect answer options:

"What other drugs do you use?" This is an appropriate question as it provides necessary information about possible polydrug use, which can impact the client's treatment plan.

"Have you tried to quit drinking before?" This is an appropriate question as it can provide insight into the client's past attempts at sobriety and may give the healthcare team information about what strategies have or have not worked for the client in the past.

"How much do you drink?" This is an appropriate question as it helps to determine the extent of the client's alcohol consumption and potential dependence, which can inform the client's treatment plan.

EXPLANATION

✔Correct answer:

Exsanguination. An external shunt creates a direct connection between an artery and a vein, which allows for the rapid flow of blood. If the shunt becomes dislodged or ruptures, the patient can rapidly lose a large volume of blood, leading to exsanguination, a life-threatening condition.

✘Incorrect answer options:

Nerve injury. While nerve injury can occur during the placement of an external shunt, it is not the most severe issue. Any nerve injury would likely be local and would not carry the same immediate, life-threatening risk as exsanguination.

Vessel sclerosis. Vessel sclerosis, or hardening of the vessels, can occur over time due to the repeated puncture of the vessels for hemodialysis. However, this is a slower process and less immediately life-threatening than exsanguination.

Bloodstream infection. Bloodstream infections are a risk with any vascular access device, including external shunts. However, while serious, they are typically not as immediately life-threatening as exsanguination.

EXPLANATION

✔Correct answer:

Use the restroom and void, saving a sample. Before a pelvic examination, the patient should be instructed to empty her bladder. This can make the examination more comfortable for the patient, and it also may be necessary for the healthcare provider to obtain a clean-catch urine sample as part of the examination.

✘Incorrect answer options:

Gather all necessary equipment for the examination. It is typically the nurse or healthcare provider's responsibility to gather the necessary equipment for the examination, not the patient's.

Remove all clothing, including socks and shoes. While the patient will need to undress from the waist down for a pelvic examination, they do not typically need to remove all clothing, including socks and shoes, unless instructed to do so by the healthcare provider.

Drink a large glass of water before the exam. Drinking a large glass of water before the exam could make the patient need to urinate during the exam, which could be uncomfortable. It is more common to be asked to drink water before a pelvic ultrasound, not a pelvic examination, as a full bladder can help with the visibility of the pelvic organs during an ultrasound.

EXPLANATION

✔Correct answer:

Fracture of the femur shaft. Intramedullary nailing is commonly used for treating fractures of the femur shaft. This procedure involves inserting a metal rod into the marrow canal of the femur. The rod passes across the fracture to help keep it in place, allowing for healing.

✘Incorrect answer options:

Slipped epiphysis of the femur. Slipped capital femoral epiphysis (SCFE) is a condition usually affecting adolescents and involves the slipping of the head of the femur off the neck of the femur. Intramedullary nailing is not the standard treatment for this condition. Instead, it is typically managed with internal fixation using screws to secure the head of the femur and prevent further slippage.

Fracture of the femur neck. A femoral neck fracture is a serious injury that often requires surgical intervention. However, intramedullary nailing is not usually the preferred method of treatment, as it may not provide sufficient stability. Instead, treatments may include internal fixation with screws or a hip arthroplasty.

Osteoporosis of the femur. Osteoporosis is a condition characterized by reduced bone density and increased risk of fracture. Treatment for osteoporosis of the femur typically focuses on increasing bone density and reducing the risk of fracture through medication, diet, and exercise, rather than surgical intervention such as intramedullary nailing.

EXPLANATION

✔Correct answer:

Inhibiting the function of cholinesterase. Neostigmine is an anticholinesterase medication, meaning it inhibits the action of the enzyme cholinesterase. This enzyme is responsible for breaking down acetylcholine, a neurotransmitter that transmits signals in the nervous system. By inhibiting cholinesterase, neostigmine increases the amount of acetylcholine available at the neuromuscular junction, enhancing muscle strength in patients with myasthenia gravis.

✘Incorrect answer options:

Speeding up transmission along neural pathways. Neostigmine does not speed up transmission along neural pathways. Instead, it increases the availability of acetylcholine, which can facilitate neural transmission at the neuromuscular junction.

Suppressing the sympathetic nervous system. Neostigmine does not suppress the sympathetic nervous system. Its primary effect is on the enzyme cholinesterase and the neurotransmitter acetylcholine, neither of which are specific to the sympathetic nervous system.

Exciting the cerebral cortex. Neostigmine does not directly excite the cerebral cortex. Its action is primarily at the neuromuscular junction, where it increases the availability of acetylcholine by inhibiting the enzyme cholinesterase.

EXPLANATION

✔Correct answer:

Administer prescribed cleansing enemas and laxatives. Before a cystectomy and ileal conduit procedure, the bowel needs to be emptied to reduce the risk of infection and complications. This is typically achieved through the administration of prescribed cleansing enemas and laxatives.

✘Incorrect answer options:

Instruct on the process of stoma irrigation. Stoma irrigation is a technique used to regulate bowel movements in individuals with a colostomy, not an ileal conduit. An ileal conduit is a urinary diversion, not a bowel diversion, so stoma irrigation would not be applicable in this case.

Restrict fluid intake for 24 hours. Fluid restriction is not typically required before a cystectomy and ileal conduit procedure. In fact, adequate hydration is important before any surgery to help prevent complications such as dehydration and thrombosis.

Give antibiotics to avert infection. While antibiotics may be given before surgery to prevent infection, this is not the primary nursing intervention in the preoperative care of a patient undergoing a cystectomy and ileal conduit procedure. The main focus is on bowel preparation, which includes administering prescribed cleansing enemas and laxatives.

EXPLANATION

✔Correct answer:

Results of anthropometric measurements. Anthropometric measurements, such as height, weight, body mass index (BMI), and skinfold thickness, are often used to assess nutritional status. In the case of a patient with Crohn's disease, these measurements can provide valuable insights into the severity of malabsorption, malnutrition, or weight loss that can occur due to chronic inflammation of the digestive tract.

✘Incorrect answer options:

Frequency of headaches. While headaches can be a symptom of various health issues, they are not directly related to nutritional status and would not provide specific information about a patient's nutritional health, especially in the context of Crohn's disease.

Occurrence of facial redness. Facial redness is not typically associated with nutritional health. It can be a symptom of many different conditions, such as rosacea, allergies, or reactions to medications or skin care products, but it is not a direct indicator of nutritional status.

Evidence of bleeding gums. Bleeding gums can be a sign of poor oral health, often due to gum disease or vitamin C deficiency (scurvy). While this can be an indicator of overall health, it is not the most comprehensive or direct measure of nutritional status, especially in a patient with Crohn's disease, which can significantly affect absorption of nutrients in the digestive tract.

EXPLANATION

✔Correct answer:

Avoid canned and processed foods, refrain from using salt replacements, use herbs and spices as substitutes for salt in cooking and seasoning foods, and consult a dietitian for assistance. This is the best option as it provides a comprehensive approach to a low-sodium diet. Canned and processed foods often have high sodium content. Herbs and spices can be used as a flavorful substitute for salt. Consulting a dietitian can provide more personalized advice and meal planning. Salt replacements should be avoided, as they often contain potassium, which can be harmful to someone with chronic renal disease due to decreased renal excretion.

✘Incorrect answer options:

Use potassium salts as a substitute for table salt when cooking and seasoning foods, read labels on packaged foods to determine sodium content, and avoid salty snacks. Potassium salts should not be used as a substitute in patients with chronic renal disease as their kidneys may not be able to excrete excess potassium, which can lead to dangerous levels of potassium in the blood.

Avoid dining at restaurants, thoroughly soak vegetables before cooking to remove sodium, exclude all canned foods, and remove salt shakers from the table. While some of these suggestions are valid, soaking vegetables does not significantly reduce sodium content. Furthermore, dining at restaurants can be done if careful choices are made.

Eliminate all carbohydrates and focus on high-protein meals without added salt. A high-protein diet can increase the workload of the kidneys and is not recommended for someone with chronic renal disease. Carbohydrates should not be eliminated.

EXPLANATION

✔Correct answer:

Inhibit the synthesis of prostaglandins. Non-narcotic analgesics like aspirin primarily work by inhibiting the synthesis of prostaglandins, hormone-like substances that play a key role in inflammation and pain. Aspirin achieves this by blocking the enzyme cyclooxygenase (COX), which is involved in prostaglandin production. By doing so, aspirin helps to reduce pain and inflammation.

✘Incorrect answer options:

Directly influences the central nervous system. While some analgesics, especially opioids, do act directly on the central nervous system to relieve pain, non-narcotic analgesics like aspirin primarily work at the site of tissue injury, inhibiting prostaglandin synthesis to decrease inflammation and pain.

Focus on the pain-inducing properties of kinins. Kinin is a generic term for certain proteins that can induce pain and inflammation. Although some drugs may work by targeting these substances, non-narcotic analgesics like aspirin primarily work by inhibiting the synthesis of prostaglandins.

Increase endorphin levels in the brain. Endorphins are naturally occurring pain-relieving chemicals in the brain, often increased in response to stress or discomfort. While some drugs, like opioids, work by mimicking the effects of endorphins, non-narcotic analgesics like aspirin do not primarily act through this mechanism.

EXPLANATION

✔Correct answer:

Coolness surrounding the insertion site. Coolness surrounding the insertion site is a common sign of IV infiltration. Infiltration occurs when the IV fluid or medication leaks into the surrounding tissue rather than going into the vein. This can cause the skin to feel cool to the touch due to the temperature of the IV fluids.

✘Incorrect answer options:

Inflammation near the insertion site. While inflammation can occur with IV infiltration, it is not the most definitive sign. Inflammation can also be a result of infection, irritation, or an allergic reaction to the IV catheter or the medication being infused.

Alteration in flow rate. An alteration in the flow rate of an IV may suggest several issues, including an occluded or kinked line, a positional change in the extremity, or a pump malfunction. It is not specifically indicative of an infiltration.

Discomfort at the site. Discomfort at the site may suggest infiltration, but it is also a common symptom of other complications such as phlebitis (inflammation of the vein), infection, or a reaction to the medication being infused. Therefore, it is not the most definitive sign of an infiltration.

EXPLANATION

✔Correct answer:

Despair, related to lack of control over disease progression. This nursing diagnosis is of high priority as it addresses the patient's emotional state which can significantly impact their overall health and well-being, as well as their ability to effectively participate in treatment plans. However, in the presence of immediate life-threatening conditions, those would take priority.

✘Incorrect answer options:

Ineffective coping, related to loss of personal boundaries. While this is an important aspect to consider in a patient's overall health, it may not be the most urgent unless it is leading to harmful behaviors or significantly impacting the patient's mental health.

Impaired cognitive function, related to lesion presence. This would be prioritized if the cognitive impairment was severe enough to pose immediate safety risks or significantly interfere with the patient's ability to participate in their care.

Compromised self-care, related to noncompliance. Noncompliance can be a significant issue in managing a patient's health, but understanding the underlying cause of the noncompliance is crucial. It may be related to other factors such as despair, ineffective coping, or impaired cognitive function.

EXPLANATION

✔Correct answer:

To alleviate muscle spasms and encourage muscle relaxation. Heat therapy is often used in chronic pain conditions, particularly those associated with muscle tension and spasms, such as lower back pain. The heat can help relax tightened muscles and alleviate spasms, thereby reducing pain.

✘Incorrect answer options:

To enhance the patient's overall circulation. While heat therapy does enhance local circulation by causing vasodilation, it does not significantly affect overall circulation. The primary purpose of applying heat in this case is to alleviate muscle spasms and promote relaxation, not to enhance systemic circulation.

To aid in clearing debris from the affected area. Heat therapy does not directly facilitate the clearance of cellular debris. This is primarily the role of the body's immune and lymphatic systems.

To maintain the patient's warmth and increase their body temperature. The primary purpose of using heat therapy in this context is not to increase the patient's body temperature or maintain their warmth. It is used to alleviate muscle spasms and promote muscle relaxation. While heat therapy can cause a local increase in temperature, this is not its main therapeutic aim in this case.

EXPLANATION

✔Correct answer:

Increased pressure on the diaphragm. The Trendelenburg position involves positioning the patient so that the head is lower than the feet. This position can increase pressure on the diaphragm due to the shifting of abdominal contents, which may make breathing more difficult.

✘Incorrect answer options:

Reduced intracranial pressure. In the Trendelenburg position, gravity can increase blood flow to the head, which might increase, rather than decrease, intracranial pressure.

Enhanced blood flow to the feet. The Trendelenburg position actually decreases blood flow to the feet due to the effects of gravity. In this position, blood is more likely to pool in the upper body and head.

Lowered blood pressure. The Trendelenburg position does not necessarily lower blood pressure. While it might decrease blood pressure in the lower extremities due to decreased blood flow, it can increase pressure in the upper body, including the head and chest.

EXPLANATION

✔Correct answer:

Undescended testicle. Cryptorchidism, or undescended testicle, is a well-established risk factor for testicular cancer. In this condition, one or both of the testes fail to descend into the scrotum before birth. Even if the condition is corrected with surgery, the increased risk remains.

✘Incorrect answer options:

Hydrocele. A hydrocele, which is a fluid-filled sac around a testicle, is common and usually isn't painful or harmful. While it may be associated with an underlying testicular condition, it is not a known risk factor for testicular cancer.

Acne. Acne is a common condition that affects the skin's oil glands but has no known connection with testicular cancer.

Genital herpes. Genital herpes is a sexually transmitted infection caused by the herpes simplex virus. There is no evidence that it increases the risk of testicular cancer.

EXPLANATION

✔Correct answer:

Head injury. Before positioning a patient who is going into shock in the modified Trendelenburg position (lying flat on their back with their legs elevated), it is crucial to assess for a head injury. This position increases blood flow to the brain, which could potentially increase intracranial pressure and worsen a head injury.

✘Incorrect answer options:

Thrombophlebitis. While it's important to be aware of potential thrombophlebitis (inflammation of a vein associated with a blood clot), it's not the primary concern when deciding to use the modified Trendelenburg position.

Air embolism. An air embolism is a serious condition that needs immediate treatment, but the risk of air embolism is not directly influenced by the modified Trendelenburg position.

Long bone fracture. While a long bone fracture could potentially be worsened by moving the patient, it's not the primary concern when deciding to use the modified Trendelenburg position, as this position could be beneficial by increasing blood return to the heart.

EXPLANATION

✔Correct answer:

Advise the patient to avoid straining during defecation. Following a prostatectomy, it's crucial to avoid any unnecessary strain on the surgical site, which could disrupt the healing process or cause complications. Straining during defecation can increase abdominal and pelvic pressure, potentially leading to bleeding or damage to the surgical area. Therefore, this intervention should take precedence.

✘Incorrect answer options:

Encourage the patient to urinate in a standing position. Typically, after a prostatectomy, a urinary catheter is left in place to ensure proper bladder drainage while the patient heals. The patient will not be able to voluntarily urinate until the catheter is removed.

Utilize a bulb syringe to draw urine from the retention catheter. This is not a common or recommended practice. A urinary catheter, if used correctly, should drain urine by gravity into a collection bag. The bag should be kept below the level of the bladder to ensure effective drainage.

Inform the primary healthcare provider if the patient fails to urinate before sleep. As mentioned, a urinary catheter is usually in place following a prostatectomy, so the patient will not need to urinate independently. Any problems with urinary output will be evident by observing the amount of urine in the collection bag.

EXPLANATION

✔Correct answer:

"Your wife is not allowing you to be independent. Let's talk about how we can help you gain more control over your care." This response is respectful and empathetic, recognizing the client's desire for independence in his care. It also opens up a discussion about strategies to improve his autonomy, which could include educating both the client and his wife about the colostomy care procedure.

✘Incorrect answer options:

"Do you think your wife might benefit from counseling?" This question could be seen as making assumptions or judgments about the wife's mental health, which may not be relevant or helpful in this situation.

"Your wife's need to help you is a reality you should accept." This statement disregards the client's feelings and his desire for independence. It's not supportive of the client's autonomy or self-efficacy.

"You feel you need privacy when changing your colostomy?" While this response acknowledges the client's feelings, it doesn't directly address the issue at hand, which is the client's desire for independence in managing his colostomy care.

EXPLANATION

✔Correct answer:

Loose rugs. Loose rugs are a significant hazard when using crutches as they can easily cause a person to slip or trip, leading to falls and potential injury. It's important to ensure that all pathways are clear and surfaces are secure to provide a safe environment for crutch usage.

✘Incorrect answer options:

4-year-old cocker spaniel. While pets can potentially be a risk due to their unpredictable movements, they don't typically present as significant a risk as environmental hazards like loose rugs. However, it's important to ensure pets are managed appropriately to minimize the risk of falls.

High noise levels. While high noise levels can be distracting, they are not typically a direct risk for safe crutch usage. However, it's always important to maintain concentration and awareness when moving with crutches.

Small snack tables. These could present a risk if they are in the path of travel, but generally, they do not pose as significant a risk as loose rugs, which can cause immediate tripping or slipping.

EXPLANATION

✔Correct answer:

Approximately 60%. The Rule of Nines is a tool used in the initial assessment of a burn patient to estimate the total body surface area (TBSA) that has been burned. In adults, this rule assigns percentages in multiples of nine to various body regions.

According to the Rule of Nines:

• The anterior trunk is 18% of the body surface area.
• Each entire upper extremity (front and back combined) is 9%, so the front of both upper extremities would account for about 9% (4.5% each).
• Each entire lower extremity is 18%, so both lower extremities would account for 36% (18% each).

Adding these together, we get: 18% (anterior trunk) + 9% (both front upper extremities) + 36% (both entire lower extremities) = 63%.

However, considering the available options and rounding up to the nearest ten, the closest correct answer is approximately 60%.

✘Incorrect answer options:

Approximately 70%. This slightly overestimates the amount of body surface area that has been burned, according to the Rule of Nines.

Approximately 90%. This overestimates the body surface area that has been burned, according to the Rule of Nines.

Approximately 50%. This significantly underestimates the extent of the burns.

EXPLANATION

✔Correct answer:

Alleviate pain and manage bleeding. Cold application or cryotherapy is often recommended for acute injuries such as a sprained ankle. The cold can help constrict the blood vessels (vasoconstriction), which can reduce bleeding into the tissues, swelling, and inflammation, thereby alleviating pain.

✘Incorrect answer options:

Facilitate the absorption of edema. While cold application can help reduce the formation of edema by decreasing the inflammatory response, it does not directly facilitate the absorption of existing edema. Once edema has formed, the body's lymphatic system will gradually absorb the fluid.

Lower the body's overall temperature. Applying cold to a localized area, such as a sprained ankle, does not significantly affect the body's overall temperature. Cold application in this context is used for its local effects, not systemic effects.

Enhance circulation to the region. Cold application actually constricts blood vessels in the applied area, reducing circulation temporarily. This is beneficial immediately after an injury as it can help minimize bleeding and swelling. However, after the acute phase of an injury, applying heat may be more beneficial to enhance circulation and promote healing.

EXPLANATION

✔Correct answer:

Away from the nurse. When opening a sterile package, the first flap should be opened away from the nurse. This is to prevent the nurse's clothing or body from coming into contact with the inside of the package, which could contaminate the sterile contents.

✘Incorrect answer options:

Open the package with both hands simultaneously. Opening the package with both hands simultaneously could potentially cause the nurse's hands or arms to come into contact with the inside of the package, contaminating the sterile contents.

Toward the nurse. Opening the first flap toward the nurse could increase the risk of contamination from the nurse's body or clothing.

Direction does not matter as long as the nurse touches only the outside edge. While it is true that the nurse should only touch the outside edge of the package to maintain sterility, the direction in which the package is opened does matter. Opening the first flap away from the nurse is a standard practice to minimize the risk of contamination

EXPLANATION

✔Correct answer:

Encouraging the patient to swim in a pool the day after surgery. After ear surgery, it's crucial to prevent water from entering the ear canal until it's fully healed, as this can lead to infection or complications. Therefore, encouraging the patient to swim in a pool the day after surgery would be inappropriate.

✘Incorrect answer options:

Assisting the client with walking at least 24 hours after surgery. Assisting the patient with walking post-surgery is appropriate care. It helps to promote circulation and prevent complications such as deep vein thrombosis (DVT).

Administering antiemetics and analgesics as prescribed. Post-surgery, it's common for patients to experience pain and nausea. Administering antiemetics and analgesics as prescribed by the physician is part of proper patient care.

Instructing the patient to avoid sneezing, coughing, and nose blowing. After ear surgery, patients should avoid actions that can increase pressure in the ears, like sneezing, coughing, and nose blowing. These actions can disrupt the healing process and potentially lead to complications.

EXPLANATION

✔Correct answer:

Activate the fire alarm or notify the operator, based on the institution's protocol. This step aligns with the "R" in the RACE protocol (Rescue, Alarm, Confine, Extinguish) for responding to fires in healthcare settings. Immediately alerting others to the presence of a fire is crucial for the safety of all patients, staff, and visitors in the building.

✘Incorrect answer options:

Retrieve a fire extinguisher and extinguish the fire. While extinguishing the fire is part of the RACE protocol, it's not the first action to take. The first action should be to raise the alarm to ensure everyone in the building is aware of the danger and can begin evacuation procedures if necessary.

Attempt to remove any burning items from the room. This action can be risky and should not be attempted before alerting others to the fire. It's important to prioritize human safety over property.

Close all windows and doors, and turn off any oxygen or electrical appliances. This is part of the "C" in the RACE protocol (Confine the fire). However, this action should be taken after raising the alarm and ensuring any patients in immediate danger have been moved to a safe location.

EXPLANATION

✔Correct answer:

Wearing a gown while caring for a 1-year-old child with infectious diarrhea. This is an example of contact precautions, a strategy used to prevent the transmission of infectious agents, including those spread by direct or indirect contact with the patient or the patient's environment. When dealing with infectious diarrhea, healthcare providers should wear personal protective equipment like gowns and gloves to prevent the spread of the pathogen.

✘Incorrect answer options:

Changing hospital linens weekly. Hospital linens should be changed more frequently than weekly, especially if they become soiled. Soiled linens can harbor infectious agents and contribute to the spread of infection.

Wearing gloves for all client contact. While gloves should be worn for any contact where there might be exposure to bodily fluids, they are not required for all client contact. Overuse of gloves can lead to skin irritation and can give a false sense of security, potentially leading to lax hand hygiene practices.

Using alcohol-based hand sanitizers instead of handwashing. While using alcohol-based hand sanitizers is an important part of hand hygiene and medical asepsis, handwashing with soap and water is necessary when hands are visibly soiled, or after caring for patients with certain infections like Clostridium difficile.

EXPLANATION

✔Correct answer:

Below the cheekbones. The maxillary sinuses are located in the cheek area just below the eyes. To palpate these sinuses, the nurse should gently press below the cheekbones. If the patient experiences pain or discomfort during this process, it may indicate inflammation or infection of the maxillary sinuses, as seen in conditions such as sinusitis.

✘Incorrect answer options:

Over the temporal area. The temporal area is located on the sides of the head near the temples, not near the maxillary sinuses.

On the forehead. This area corresponds to the frontal sinuses, not the maxillary sinuses.

On the bridge of the nose. The bridge of the nose is not the location of the maxillary sinuses. The ethmoid and sphenoid sinuses are closer to this area.

EXPLANATION

✔Correct answer:

"Tell me about what you think." Responding with "Tell me about what you think" invites the patient to share their feelings and fears, promoting open communication. This approach shows empathy and understanding, while respecting the patient's emotional state.

✘Incorrect answer options:

"I'm sure you are scared; other clients in your situation feel the same way." While this response acknowledges the patient's fear, it may not be fully comforting. Comparing the patient's feelings to others may seem dismissive or make the patient feel as though their fears are being minimized.

"You will be alright, don't worry." This response may seem comforting, but it may not be truthful or respectful to the patient's condition or feelings. It's important to be honest and supportive without providing false hope.

"You should be careful not to let your family know you're scared." This response may discourage the patient from sharing their feelings with their family or loved ones, which can lead to feelings of isolation. It's crucial to encourage open communication and emotional support during this difficult time.

EXPLANATION

✔Correct answer:

Hyperglycemia and Hypokalemia. Total Parenteral Nutrition (TPN) is a form of intravenous feeding that provides patients with all of the nutrients they need when they cannot eat or absorb enough nutrients from food. TPN provides carbohydrates, proteins, fats, vitamins, minerals, and electrolytes.

• Hyperglycemia: TPN contains a high concentration of glucose (dextrose), which can lead to high blood sugar levels (hyperglycemia), especially in patients with diabetes or in those who cannot metabolize glucose effectively.
• Hypokalemia: Although TPN often contains potassium, the balance of electrolytes can be complex and individual reactions can vary. Hypokalemia is caused by the loss of potassium in the urine, which is increased by the high concentration of glucose in TPN solutions.

✘Incorrect answer options:

Hyperglycemia and Hyperkalemia: While hyperglycemia is common with TPN, hyperkalemia is not necessarily common as potassium levels can vary depending on individual patient factors.

Hypoglycemia and Hypercalcemia: Hypoglycemia is not common with TPN due to the high glucose content. Hypercalcemia is also not a common complication of TPN.

Hyperkalemia and Hypercalcemia: While hyperkalemia can potentially occur, it's not necessarily common. Also, hypercalcemia is not typically associated with TPN.

Please note that individual patient reactions can vary, and this is why careful monitoring of all TPN patients is essential.

EXPLANATION

✔Correct answer:

Prevents flexion contractures. Positioning a patient who has had an above-the-knee amputation in a prone position several times a day can help prevent hip flexion contractures. Contractures occur when there is a shortening and hardening of muscles, tendons, or other tissue, often leading to rigidity and deformity. In this case, regular prone positioning can help maintain the range of motion and prepare the limb for a potential prosthesis.

✘Incorrect answer options:

Facilitates better blood flow to the heart. While certain positions can help with blood flow, the prone position is not specifically used for this purpose in the context of a leg amputation.

Ensures proper fit of the prosthesis. While preventing contractures can eventually help with the fit of a prosthesis, the positioning itself does not ensure the proper fit of the prosthesis.

Promotes wound dehiscence. Wound dehiscence, the separation of the edges of a surgical wound, is a complication and not a desired outcome. The prone position does not promote wound dehiscence.

EXPLANATION

✔Correct answer:

Apply a cold compress to minimize swelling. Applying a cold compress to the injection site can help to reduce inflammation and provide relief from the burning sensation and discomfort. The cold temperature can constrict the blood vessels, which may help to minimize any swelling or inflammation at the site.

✘Incorrect answer options:

Place a warm compress on the site to promote vasodilation. While warm compresses can be beneficial for certain conditions, they may not be the best choice immediately after an injection if there's discomfort or inflammation. Warm compresses promote vasodilation, which can increase blood flow and potentially exacerbate inflammation.

Advise the client to contract their gluteal muscles to enhance drug absorption. Contracting the muscles may not necessarily enhance drug absorption and could potentially cause more discomfort or pain.

Elevate the affected extremity. While this might be useful for conditions like sprains or injuries to reduce swelling, it may not be specifically beneficial for discomfort at an injection site.

EXPLANATION

✔Correct answer:

Speaking slowly and audibly. For a client who relies on lip-reading for communication, the nurse should speak slowly and audibly. This will enable the client to read the nurse's lips better and understand the communication. The nurse should also maintain eye contact and ensure their mouth is visible to the client.

✘Incorrect answer options:

Speaking with accompanying gestures. While gestures can sometimes support communication, they are not a reliable primary means of communication. Gestures can be misinterpreted, and not all words or concepts have easily understandable gestures. Therefore, this method should be used as a support to verbal communication rather than the primary means of communication.

Employing a basic "charades" approach or strategy. This approach can be challenging and frustrating for both the nurse and the client. It may lead to misinterpretations and miscommunication. Like gestures, this should not be the primary means of communication.

Speaking softly and using a low tone. Speaking softly can be problematic for someone who relies on lip-reading. They may not be able to see the movements of the nurse's lips as well, which can lead to misunderstandings. A normal or slightly louder volume (without shouting) is more appropriate.

EXPLANATION

✔Correct answer:

Reduced serum potassium levels. Reduced serum potassium levels, also known as hypokalemia, are not typically associated with the development of metabolic acidosis. While severe hypokalemia can affect the body's acid-base balance, it does not typically cause metabolic acidosis.

✘Incorrect answer options:

Kidney failure. Kidney failure can lead to metabolic acidosis. The kidneys play a crucial role in maintaining acid-base balance by excreting hydrogen ions and reabsorbing bicarbonate. In kidney failure, this function is impaired, leading to an accumulation of acids in the body.

Heart attack. A heart attack, or myocardial infarction, can lead to metabolic acidosis due to tissue hypoxia and the subsequent production of lactic acid.

Diabetic ketoacidosis. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones. The condition develops when the body can't produce enough insulin, leading to an accumulation of ketones and resulting in metabolic acidosis.

EXPLANATION

✔Correct answer:

Inquire if the patient has any concerns regarding his care. Inquiring about a patient's concerns regarding his care is an important initial response because it can help the nurse understand the patient's needs, worries, or potential misunderstandings. This communication can often clarify the information the patient seeks and can sometimes eliminate the need to view the chart. Also, it creates an open dialogue where the nurse can provide explanations, reassurances, and education about the patient's condition and treatment.

✘Incorrect answer options:

Seek approval from the supervisor and physician. This option is not necessarily wrong, but it isn't the best initial action. While some institutions may require approval for a patient to view their chart, the Health Insurance Portability and Accountability Act (HIPAA) generally allows patients the right to view and obtain a copy of their health records. However, the first step should be to understand the patient's concerns, not to seek approval.

Offer the patient a blank chart for review. This is incorrect because offering a blank chart would not address the patient's request. A blank chart does not contain any information about the patient's health, diagnoses, or treatment, so it would not be helpful or relevant.

Inform the patient that he is not allowed to access his chart. This is incorrect. Under the Health Insurance Portability and Accountability Act (HIPAA), patients have the right to view and obtain a copy of their health records. This includes their charts, which contain important medical information about their diagnoses, treatments, and progress.

EXPLANATION

✔Correct answer:

Provide the patient with a narcotic analgesic. Before debriding a burn wound, it's crucial to medicate the patient with a narcotic analgesic. Debridement, the process of removing dead tissue from a burn, can be very painful. Thus, ensuring adequate pain relief with an analgesic prior to the procedure is necessary for patient comfort.

✘Incorrect answer options:

Administer intravenous acyclovir (Zovirax). Administering acyclovir (Zovirax) is not the best action before debridement. Acyclovir is an antiviral medication used to treat herpes simplex and varicella-zoster viruses. It is not typically used in the management of burns unless there is a specific indication (e.g., the patient has a concurrent viral infection).

Apply Lindane (Kwell) to the impacted area. Lindane (Kwell) is a medication used to treat scabies and lice, and it is not typically used in burn care. Applying this medication before debridement would not provide any benefit.

Position the affected leg in a dependent manner. Positioning the affected leg in a dependent manner is not the most appropriate action to take before debriding a burn wound. Elevating the burned area can help reduce swelling, but it's not the primary concern prior to debridement. Instead, ensuring the patient's comfort through adequate pain management is a priority.