When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as a) clean contaminated. Clean-contaminated cases are those with a potential, limited source for infection, the exposure to which, to a large extent, can be controlled. b) clean. Clean cases are those with no apparent source of potential infection. c) contaminated. Contaminated cases are those that contain an open and obvious source of potential infection. d) dirty. A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered a dirty case.

When the surgeon performs an appendectomy, the nurse
recognizes that the surgical category will be identified as
a) clean contaminated.
Clean-contaminated cases are those with a potential, limited source for
infection, the exposure to which, to a large extent, can be controlled.
b) clean.
Clean cases are those with no apparent source of potential infection.
c) contaminated.
Contaminated cases are those that contain an open and obvious
source of potential infection.
d) dirty.
A traumatic wound with foreign bodies, fecal contamination, or
purulent drainage would be considered a dirty case.
by

1 Answer

Answer :

a) clean contaminated.
Clean-contaminated cases are those with a potential, limited source for
infection, the exposure to which, to a large extent, can be controlled.
by

Related questions

The first dressing change for an autografted area is performed a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately.

Description : The first dressing change for an autografted area is performed a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent ... is noted. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

Last Answer : a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately.

When the patient has been field triaged and categorized as blue, the nurse recognizes that the patient requires a) fast-track or psychological support. When a patient is categorized as blue, field triage has identified fasttrack or psychological support needs.

Description : When the patient has been field triaged and categorized as blue, the nurse recognizes that the patient requires a) fast-track or psychological support. When a patient is categorized as blue, field ... . d) urgent care. Field triaged patients who require urgent care will be categorized as green.

Last Answer : a) fast-track or psychological support. When a patient is categorized as blue, field triage has identified fasttrack or psychological support needs.

After the last stitch, the surgeon is ready to apply dressing to the incision wound. Which of the following does the nurse expect the surgeon to do? A. Remove his gloves and apply the dressing B. Apply the dressings and tape and then remove his gloves C. Put the dressings and remove his gloves to apply the tape D. Tape the dressing and remove the gloves

Description : After the last stitch, the surgeon is ready to apply dressing to the incision wound. Which of the following does the nurse expect the surgeon to do? A. Remove his gloves and apply the dressing B. ... the dressings and remove his gloves to apply the tape D. Tape the dressing and remove the gloves

Last Answer : C. Put the dressings and remove his gloves to apply the tape

Wounds are classified according to the likelihood of bacterial contamination. Which of the following statement(s) is/are true concerning wound classifications? a. A clean-contaminated wound would be that associated with an elective colon resection with adequate mechanical and antibiotic bowel preparation b. A contaminated wound would include a resection of obstructed bowel with gross spillage of intestinal contents c. In a clean wound, no viscus is entered d. Antibiotic prophylaxis should be administered for all clean-contaminated and contaminated wounds and selectively in patients involving a clean wound

Description : Wounds are classified according to the likelihood of bacterial contamination. Which of the following statement(s) is/are true concerning wound classifications? a. A clean-contaminated wound would ... all clean-contaminated and contaminated wounds and selectively in patients involving a clean wound

Last Answer : Answer: a, b, c, d Wounds are classified under three classes according to the likelihood of bacterial contamination: 1) clean (no viscus is entered; e.g., herniorrhaphy); 2) clean- ... tenet involves cases in which a prosthetic material may be used (artificial joint, heart valve, tissue patch)

A patient with gross fecal contamination and peritonitis from a ruptured sigmoid diverticulum has his midline wound left open to heal by secondary intention. Which of the following statement(s) describes this healing process? a. Wounds healing in this fashion have an altered sequence of healing compared to a primarily closed wound b. A bed of granulation tissue forms over exposed subcutaneous tissue c. Epithelialization is enhanced in the face of bacterial colonization d. The ability of a wound to form granulation tissue is dependent on the blood supply of the tissue

Description : A patient with gross fecal contamination and peritonitis from a ruptured sigmoid diverticulum has his midline wound left open to heal by secondary intention. Which of the following statement(s) describes this ... of a wound to form granulation tissue is dependent on the blood supply of the tissue

Last Answer : Answer: b, d Open wounds, whether they be ulcers or open surgical incisions closing by secondary intention, heal with the same sequence of inflammation, matrix deposition, epithelialization ... via bacterial and phagocytic cell products such as proteases, collagenases, elastases, and other enzymes

When the patient who has undergone laryngectomy suffers wound breakdown, the nurse monitors him very carefully because he is identified as being at high risk for a) carotid artery hemorrhage. The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly. b) pulmonary embolism. Pulmonary embolism is associated with immobility. c) dehydration. Dehydration may lead to poor wound healing and breakdown. d) pneumonia. Pneumonia is a risk for any postoperative patient.

Description : When the patient who has undergone laryngectomy suffers wound breakdown, the nurse monitors him very carefully because he is identified as being at high risk for a) carotid artery hemorrhage. The ... poor wound healing and breakdown. d) pneumonia. Pneumonia is a risk for any postoperative patient.

Last Answer : a) carotid artery hemorrhage. The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly.

The nurse who effectively analyzes the communication process recognizes the messages are A. Connotative and denotative B. Learned and unlearned C. Verbal and non-verbal D. Native as well as foreign

Description : The nurse who effectively analyzes the communication process recognizes the messages are A. Connotative and denotative B. Learned and unlearned C. Verbal and non-verbal D. Native as well as foreign

Last Answer : C. Verbal and non-verbal

When measuring the blood pressure in each of the patient’s arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. b) must be equal in both arms. The pressures in each arm do not have to be equal in order to be considered normal. c) may vary 10 mm Hg or more between arms. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. d) may vary, with the higher pressure found in the left arm. The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Description : When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in ... . The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Last Answer : a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures.

As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the top dressing B. Continue to monitor the vital signs C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Description : As the nurse monitors the client, she notices a bright red spot on the dressings which measures 4cm in diameter. The nurse should initially do which appropriate nursing intervention? A. Change the ... C. Notify the clients surgeon of a potential hemorrhage D. Assess the presence of a drain

Last Answer : D. Assess the presence of a drain

The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, “I will A. Call you when the return flow is clear” B. Stop the enema only if the return flow is without formed fecal material” C. Need 1 liter of tap water to have clear return flow” D. Put the client in left Sim’s position to achieve the desired return flow.”

Description : The nurse instructs the nursing attendant to perform cleansing enema until the return flow is clear. The nursing attendant understood the instruction when she says, I will A. Call you when the return flow is ... flow D. Put the client in left Sim's position to achieve the desired return flow.

Last Answer : A. Call you when the return flow is clear”

79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, “How old is the client?” Holding the fallopian tube, the surgeon asks for a hemostat. The scrub nurse sensing that the surgeon is about to ligate the tube said, “Doctor there is no signed consent for tubal ligation.” The nurse just demonstrated which of the following?

Description : 79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, How old is the client? Holding the fallopian ... there is no signed consent for tubal ligation. The nurse just demonstrated which of the following?

Last Answer : C. Advocacy

Which of the following terms is given to hypertension in which the blood pressure, which is controlled with therapy, becomes uncontrolled (abnormally high) with the discontinuation of therapy? a) Rebound Rebound hypertension may precipitate a hypertensive crisis. b) Essential Essential or primary hypertension denotes high blood pressure from an unidentified source. c) Primary Essential or primary hypertension denotes high blood pressure from an unidentified source. d) Secondary Secondary hypertension denotes high blood pressure from an identified cause, such as renal disease.

Description : Which of the following terms is given to hypertension in which the blood pressure, which is controlled with therapy, becomes uncontrolled (abnormally high) with the discontinuation of therapy? ... Secondary hypertension denotes high blood pressure from an identified cause, such as renal disease.

Last Answer : a) Rebound Rebound hypertension may precipitate a hypertensive crisis.

When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse recognizes that the patient is likely demonstrating signs of a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

Description : When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse ... heterotrophic ossification. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.

Last Answer : a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

When the nurse notes that the patient’s left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) hammertoe. Hammertoes are usually pulled upward. c) pes cavus. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Description : When the nurse notes that the patient's left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) ... the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Last Answer : a) hallux valgus. Hallux valgus is commonly referred to as a bunion.

The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

Description : The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a ... . d) local arterial insufficiency. Local arterial insufficiency is characterized by marked localized pallor.

Last Answer : a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

Description : When the nurse assesses the patient and observes blue-red and dark brown plaques and nodules, she recognizes that these manifestations are associated with a) Kaposi's sarcoma. Kaposi's sarcoma is ... syphilis. A painless chancre or ulcerated lesion is a typical finding in the patient with syphilis.

Last Answer : a) Kaposi’s sarcoma. Kaposi’s sarcoma is a frequent comorbidity of the patient with AIDS.

When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Description : When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) ... urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.

Last Answer : a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

The nurse recognizes which of the following statements as accurately reflecting a risk factor for breast cancer? a) Mother affected by cancer before 60 years of age Risk for breast cancer increases twofold if first-degree female relatives (sister, mother, or daughter) had breast cancer.

Description : The nurse recognizes which of the following statements as accurately reflecting a risk factor for breast cancer? a) Mother affected by cancer before 60 years of age Risk for breast cancer increases ... in women who consume even one drink daily and doubles among women drinking three drinks daily.

Last Answer : a) Mother affected by cancer before 60 years of age Risk for breast cancer increases twofold if first-degree female relatives (sister, mother, or daughter) had breast cancer.

When the female patient demonstrates thickening, scaling, and erosion of the nipple and areola, the nurse recognizes that the patient is exhibiting signs of a) Paget’s disease. Paget’s disease is a malignancy of mammary ducts with early signs of erythema of nipple and areola. b) acute mastitis. Acute mastitis is demonstrated by nipple cracks or abrasions along with reddened and warm breast skin and tenderness.

Description : When the female patient demonstrates thickening, scaling, and erosion of the nipple and areola, the nurse recognizes that the patient is exhibiting signs of a) Paget's disease. Paget's disease ... the breast and demonstrates an orange peel apearance of breast skin with enlargement of skin pores.

Last Answer : a) Paget’s disease. Paget’s disease is a malignancy of mammary ducts with early signs of erythema of nipple and areola.

When the results of a Pap smear are reported as class 5, the nurse recognizes that the common interpretation is a) malignant. A class 5 Pap smear, according to the Bethesda Classification, indicates squamous cell carcinoma. b) normal. A class 1 Pap smear is interpreted as normal. c) probably normal. A class 2 Pap smear is interpreted as probably normal. d) suspicious. A class 3 Pap smear is interpreted as suspicious.

Description : When the results of a Pap smear are reported as class 5, the nurse recognizes that the common interpretation is a) malignant. A class 5 Pap smear, according to the Bethesda Classification, ... is interpreted as probably normal. d) suspicious. A class 3 Pap smear is interpreted as suspicious.

Last Answer : a) malignant. A class 5 Pap smear, according to the Bethesda Classification, indicates squamous cell carcinoma.

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief. b) vomiting. Vomiting is uncommon in the patient with duodenal ulcer. c) hemorrhage. Hemorrhage is less likely in the patient with duodenal ulcer than the patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

Description : When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the ... or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

Last Answer : a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is an indicator of shock. c) Warm, dry skin Skin is generally cool and moist in shock. d) Increased urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Description : The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is ... urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Last Answer : a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening. b) urgent. Urgent surgery means that the patient requires prompt attention within 24-30 hours. c) required. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. d) elective. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

The nurse who admitted the patient recognizes that Billroth II procedure means A. Enterostomy B. Esophagojejunostomy C. Gastroduodenostomy D. Gastrojejunostomy

Description : The nurse who admitted the patient recognizes that Billroth II procedure means A. Enterostomy B. Esophagojejunostomy C. Gastroduodenostomy D. Gastrojejunostomy

Last Answer : D. Gastrojejunostomy

The nurse teaches the patient about diabetes including which of the following statements? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

Description : The nurse teaches the patient about diabetes including which of the following statements? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood ... be able to resume previous methods for control of diabetes when the stress is resolved.

Last Answer : a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

A 59-year-old trauma patient has suffered multiple septic complications including severe pneumonia, intraabdominal abscess, and major wound infection. He has now developed signs of multisystem organ failure. Which of the following statement(s) is/are true concerning necessary changes to be made in his nutritional management? a. Carbohydrate load should be reduced in the face of respiratory failure b. In patients with renal failure, protein intake should be diminished c. During hemodialysis protein intake should be limited to the same extent d. In patients with hepatic failure, carbohydrate load should be increased

Description : A 59-year-old trauma patient has suffered multiple septic complications including severe pneumonia, intraabdominal abscess, and major wound infection. He has now developed signs of multisystem organ ... the same extent d. In patients with hepatic failure, carbohydrate load should be increased

Last Answer : Answer: a, b The most severe complication of sepsis is multiple system organ dysfunction syndrome, which may result in death. The development of organ failure requires changes in the ... should be provided as fat emulsion. If encephalopathy develops, protein load should also be reduced0

85. When the surgeon asked for suture to close the abdomen, sponge count has not been completed. Which of the following is the appropriate action of the scrub nurse?

Description : 85. When the surgeon asked for suture to close the abdomen, sponge count has not been completed. Which of the following is the appropriate action of the scrub nurse?

Last Answer : D. Informs the surgeon that sponge count has not been completed

The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Description : The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Last Answer : A. Gastric decompression

In the immediate post-operative period, the nurse assesses coarse, high-pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should immediately A. Position client to Fowler’s B. Reassure the client that he is doing fine C. Suction the tracheostomy tube D. Report to the surgeon

Description : In the immediate post-operative period, the nurse assesses coarse, high-pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should immediately A. Position client to ... the client that he is doing fine C. Suction the tracheostomy tube D. Report to the surgeon

Last Answer : Which of the following expected outcomes for the patient is most relevant for the nursing diagnosis “At risk for imbalanced nutrition related to impaired swallowing”? A. Appropriate body weight maintained B. Fear of choking relieved C. Oral intake increased D. Swallowing of soft foods facilitated

Which of the following terms is used to refer to protrusion of abdominal organs through the surgical incision? a) Evisceration Evisceration is a surgical emergency. b) Hernia A hernia is a weakness in the abdominal wall. c) Dehiscence Dehiscence refers to partial or complete separation of wound edges. d) Erythema Erythema refers to redness of tissue.

Description : Which of the following terms is used to refer to protrusion of abdominal organs through the surgical incision? a) Evisceration Evisceration is a surgical emergency. b) Hernia A hernia is a weakness ... partial or complete separation of wound edges. d) Erythema Erythema refers to redness of tissue.

Last Answer : a) Evisceration Evisceration is a surgical emergency.

33. The client is scheduled to undergo appendectomy. Preparation for appendectomy includes the following: 1. Intravenous infusion 2. Laxative 3. Pubic area shaving 4. Enema 5. Shower 6. Pain medication

Description : 33. The client is scheduled to undergo appendectomy. Preparation for appendectomy includes the following: 1. Intravenous infusion 2. Laxative 3. Pubic area shaving 4. Enema 5. Shower 6. Pain medication

Last Answer : B. 1, 3, and 5

When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for redness and palpated for hardening. b) drainage. Drainage at the site does not indicate a reaction to the tubercle bacillus. c) tissue sloughing. Sloughing of tissue at the site of injection does not indicate a reaction to the tubercle bacillus. d) bruising. Bruising of tissue at the site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Description : When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for ... site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Last Answer : a) redness and induration. The site is inspected for redness and palpated for hardening.

30. A T-tube was inserted and the physician ordered, “Monitor the amount, color, consistency and odor of drainage.” Which of the following procedures can the nurse perform without the doctor’s order?

Description : 30. A T-tube was inserted and the physician ordered, “Monitor the amount, color, consistency and odor of drainage.” Which of the following procedures can the nurse perform without the doctor’s order?

Last Answer : D. Emptying the drainage

When the post-cardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects which of the following electrolyte imbalances? a) Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, cardiac arrest.

Description : When the post-cardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects ... and QT intervals, broad flat T waves), disorientation, depression, and hypotension.

Last Answer : a) Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, cardiac arrest.

Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

Description : Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest ... finding to the physician immediately. Subcutaneous emphysema results from air entering the tissue planes.

Last Answer : a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

84. The circulating nurse will document “surgical count” in which of the following?

Description : 84. The circulating nurse will document “surgical count” in which of the following?

Last Answer : B. Intraoperative record

When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Description : When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement ... Pancrease. Commercially available enzymatic debriding agents include Accuzyme, Clooagenase, Granulex, and Zymase.

Last Answer : a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Pre-operatively, the nurse identified the nursing dagnosis, “Knowledge Deficit: Post-operative communication strategies”. Which of the following is a relevant nursing intervention? A. Clarify information on purpose, anticipate benefits and consequences of total laryngectomy B. Explain that total laryngectomy results in loss of ability to verbally communicate C. Arrange a visit to a post-laryngectomy client who effectively uses an alternative form of verbal communication D. Illustrate means of communicating post- operatively

Description : Pre-operatively, the nurse identified the nursing dagnosis, Knowledge Deficit: Post-operative communication strategies . Which of the following is a relevant nursing intervention? A. ... uses an alternative form of verbal communication D. Illustrate means of communicating post- operatively

Last Answer : D. Illustrate means of communicating post- operatively

The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could become activated with exposure to strong light, such as sunlight or bright lights. Ordinary indoor light is not a problem. The patient should be counseled to wear protective clothing, such as long-sleeved shirts, sunglasses, and wide-brimmed hats, if the patient has to go outdoors during daylight hours in the first five days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Description : The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. ... should avoid exposure to direct sunlight or bright lights for the first five days post-treatment.

Last Answer : a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could ... days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

A 55-year-old renal transplant patient has been hospitalized in a Surgical Intensive Care Unit, receiving a prolonged course of antibiotics following an attack of acute cholecystitis. The following statement(s) is/are true concerning his management. a. Due to the potential risk of Candida infection, prophylaxis with oral nystatin should be instituted early in the patient’s course b. A Candida urinary tract infection should be treated with systemic amphotericin B c. Changes of Candida retinitis are of little significance d. The presence of a virulent Candida bacteremia should suggest a dosage reduction in immunosuppressive agents until the infection can be adequately controlled

Description : A 55-year-old renal transplant patient has been hospitalized in a Surgical Intensive Care Unit, receiving a prolonged course of antibiotics following an attack of acute cholecystitis. The ... suggest a dosage reduction in immunosuppressive agents until the infection can be adequately controlled

Last Answer : Answer: a, d Infections due to fungal pathogens have become increasingly common during the past decade, frequently occurring in patients undergoing prolonged hospitalization in the Surgical ... agents should be discontinued until evidence of infection is absolutely controlled or is eradicated

During which step of the nursing process does the nurse analyze data related to the patient’s health status? a) Assessment Analysis of data is included as part of the assessment. b) Implementation Implementation is the actualization of the plan of care through nursing interventions. c) Diagnosis Diagnosis is the identification of patient problems. d) Evaluation Evaluation is the determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved.

Description : During which step of the nursing process does the nurse analyze data related to the patient's health status? a) Assessment Analysis of data is included as part of the assessment. b) ... patient's responses to the nursing interventions and the extent to which the outcomes have been achieved.

Last Answer : a) Assessment Analysis of data is included as part of the assessment.

If a case of smallpox is suspected, the nurse should a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office at 770-488-7100. The CDC will respond by immmediate provision of diagnostic support and eventual release of vaccine if a case is confirmed. Until instructed otherwise by the CDC, healthcare providers should carefully establish isolation with negative pressure, and maintain thorough lists of all those who have contact with the patient.

Description : If a case of smallpox is suspected, the nurse should a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office ... very different from that of chickenpox. With chickenpox, lesions appear at different developmental stages.

Last Answer : a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office at 770-488-7100. The CDC will respond by immmediate provision ... with negative pressure, and maintain thorough lists of all those who have contact with the patient.

Prophylactic use of antibiotics is not justified in the following condition: A. To prevent secondary infection in common cold B. Thoroughly cleaned contaminated wound C. Rheumatic fever in a child of 10 years D. Catheterization of urethra in an elderly male

Description : Prophylactic use of antibiotics is not justified in the following condition: A. To prevent secondary infection in common cold B. Thoroughly cleaned contaminated wound C. Rheumatic fever in a child of 10 years D. Catheterization of urethra in an elderly male

Last Answer : A. To prevent secondary infection in common cold

More than 500 CD4+ T lymphocytes/mm3 indicates which stage of HIV infection? a) CDC category A - HIV asymptomatic More than 500 CD4+ T lymphocytes/mm3 indicates CDC category A - HIV asymptomatic.

Description : More than 500 CD4+ T lymphocytes/mm3 indicates which stage of HIV infection? a) CDC category A - HIV asymptomatic More than 500 CD4+ T lymphocytes/mm3 indicates CDC category A - HIV asymptomatic. b) ... CDC category C - AIDS Less than 200 CD4+ T lymphocytes/mm3 indicates CDC category C - AIDS.

Last Answer : a) CDC category A - HIV asymptomatic More than 500 CD4+ T lymphocytes/mm3 indicates CDC category A - HIV asymptomatic.

The nurse teaches the patient who demonstrates herpes zoster (shingles) that a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity.

Description : The nurse teaches the patient who demonstrates herpes zoster (shingles) that a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a ... is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.

Last Answer : a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity.

When the female client reports a frothy yellow-brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by a) trichomonas vaginalis. Trichomonas vaginalis causes a frothy yellow-white or yellow-brown vaginal discharge.

Description : When the female client reports a frothy yellow-brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by a) trichomonas vaginalis. Trichomonas vaginalis causes a ... the external vulva and vaginal walls. d) chlamydia. Chlamydia causes a profuse purulent discharge.

Last Answer : a) trichomonas vaginalis. Trichomonas vaginalis causes a frothy yellow-white or yellow-brown vaginal discharge.