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Question 1:

A nurse is assessing a client who had an appendectomy 24 hours ago. The nurse observes redness, warmth, swelling, and purulent drainage at the incision site. The nurse suspects that the client has developed:

A. A wound infection. B. A wound dehiscence. C. A wound evisceration. D. A wound hematoma.

Answer and Explanation

Choice A:

A wound infection is the most likely diagnosis for a client who has redness, warmth, swelling, and purulent drainage at the incision site 24 hours after an appendectomy. These are signs of inflammation and infection that indicate the wound is not healing properly. A wound infection can delay wound healing, increase pain, and cause fever and systemic symptoms. A wound infection requires treatment with antibiotics and wound care.

Choice B:

A wound dehiscence is a partial or complete separation of the edges of a surgical incision. It usually occurs later than 24 hours after surgery, when the wound is still fragile and weak. A wound dehiscence can be caused by stress on the wound, such as coughing, vomiting, or straining, or by poor wound closure, infection, or malnutrition. A wound dehiscence may present with increased drainage, a visible gap in the incision, or a popping sensation. A wound dehiscence requires immediate medical attention and may need surgical repair.

Choice C:

A wound evisceration is a rare but serious complication of a wound dehiscence, where the abdominal organs protrude through the open incision. It is a surgical emergency that requires immediate intervention to prevent organ damage, infection, and shock. A wound evisceration may present with sudden pain, a gush of blood or serous fluid, and visible organs through the wound. The client should lie down with knees bent and cover the wound with a sterile dressing moistened with warm saline until help arrives.

Choice D:

A wound hematoma is a collection of blood under the skin or in the deeper tissues that results from bleeding at the surgical site. It usually occurs within the first few hours after surgery and may cause swelling, pain, bruising, and pressure on nearby structures. A wound hematoma can increase the risk of infection and impair wound healing. A small hematoma may resolve on its own, while a large hematoma may need drainage or surgery.

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Question 2:

A nurse is assisting with the induction of general anesthesia for a client who is undergoing a cholecystectomy. The nurse monitors the client for signs of malignant hyperthermia, which include:

A. Hypothermia, bradycardia, and hypotension. B. Hyperthermia, tachycardia, and hypertension. C. Hypothermia, tachypnea, and hypertension. D. Hyperthermia, bradypnea, and hypotension.

Answer and Explanation

Choice A:

Hypothermia, bradycardia, and hypotension are not signs of malignant hyperthermia, but rather signs of hypovolemia, shock, or anesthesia overdose. Malignant hyperthermia is a rare but life-threatening condition that occurs when a patient is exposed to certain anesthetic agents and develops a hypermetabolic response that leads to high fever, muscle rigidity, tachycardia, hypertension, acidosis, and rhabdomyolysis.

Choice B:

Hyperthermia, tachycardia, and hypertension are the classic signs of malignant hyperthermia. The patient may also experience increased carbon dioxide production, decreased oxygen saturation, dysrhythmias, cyanosis, muscle breakdown, and organ failure. The nurse should monitor the patient's vital signs, temperature, blood gases, electrolytes, and urine output closely and notify the anesthesia care provider immediately if malignant hyperthermia is suspected. The treatment involves stopping the anesthetic agent, administering 100% oxygen, cooling the patient with ice packs and cold intravenous fluids, and giving dantrolene sodium intravenously to relax the muscles.

Choice C:

Hypothermia, tachypnea, and hypertension are not consistent with malignant hyperthermia. Hypothermia may occur due to exposure to cold operating room environment or intravenous fluids. Tachypnea may be caused by pain, anxiety, hypoxia, or acidosis. Hypertension may be related to stress, pain, or sympathetic stimulation. These signs are not specific to malignant hyperthermia and do not indicate a hypermetabolic state.

Choice D:

Hyperthermia, bradypnea, and hypotension are not typical of malignant hyperthermia. Hyperthermia may occur due to infection, inflammation, or dehydration. Bradypnea may be a result of oversedation, opioid administration, or respiratory depression. Hypotension may be due to blood loss, dehydration, or vasodilation. These signs do not reflect a hypermetabolic state or muscle rigidity that are characteristic of malignant hyperthermia.

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Question 3:

A nurse is evaluating the discharge instructions for a client who had a mastectomy with lymph node dissection. The nurse instructs the client to avoid:

A. Wearing tight-fitting clothing or jewelry on the affected arm. B. Elevating the affected arm above the level of the heart. C. Applying moisturizer or sunscreen to the affected arm. D. Having blood pressure or blood draws on the affected arm. E. Performing range-of-motion exercises on the affected arm.

Answer and Explanation

Choice A:

Wearing tight-fitting clothing or jewelry on the affected arm is not recommended, but it is not something to avoid completely. Tight-fitting clothing or jewelry can cause swelling (lymphedema) or infection in the arm, but wearing them for short periods of time may be acceptable. The client should be advised to wear loose-fitting clothing and jewelry most of the time and to monitor the arm for any signs of swelling, pain, or redness.

Choice B:

Elevating the affected arm above the level of the heart is not something to avoid, but rather something to do frequently. Elevating the arm can help reduce swelling and improve blood flow. The client should be instructed to elevate the arm several times a day for 15 to 30 minutes at a time.

Choice C:

Applying moisturizer or sunscreen to the affected arm is not something to avoid, but rather something to do regularly. Moisturizer can help prevent dryness and cracking of the skin, which can increase the risk of infection. Sunscreen can help protect the skin from sun damage, which can also increase the risk of infection and skin cancer. The client should be advised to apply moisturizer daily and sunscreen whenever exposed to the sun.

Choice D:

Having blood pressure or blood draws on the affected arm is something to avoid. This is because these procedures can cause injury or infection to the arm, which can lead to lymphedema or other complications. The client should be instructed to inform all health care providers that they had a mastectomy with lymph node dissection and to request that blood pressure or blood draws be done on the other arm or on another part of the body.

Choice E:

Performing range-of-motion exercises on the affected arm is not something to avoid, but rather something to do gradually and carefully. Range-of-motion exercises can help restore mobility and flexibility to the arm and prevent stiffness and contractures. The client should be instructed to start doing gentle exercises as soon as possible after surgery and to increase the intensity and duration as tolerated. The client may be referred to a physical therapist for additional guidance and support.

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Question 4:

A nurse is caring for a client who is scheduled for an abdominal hysterectomy under general anesthesia. The client asks what type of anesthesia will be used and how it will affect her. Which of the following responses should the nurse give?

A. "General anesthesia will make you unconscious and unable to feel any pain during the surgery.” B. "General anesthesia will numb your lower body and allow you to remain awake during the surgery.” C. "General anesthesia will block pain signals from reaching your brain and make you sleepy during the surgery.” D. "General anesthesia will relax your muscles and reduce your awareness of what is happening during the surgery.”

Answer and Explanation

Choice A:

General anesthesia will make you unconscious and unable to feel any pain during the surgery. This is true because general anesthesia affects the whole body and brain, blocking the sensation of pain and awareness of the surroundings. General anesthesia is used for almost all laparoscopic hysterectomies and is often used for abdominal and vaginal hysterectomies. General anesthesia also impairs your breathing, so a breathing tube, ventilator, and inhalation anesthetic may be used.

Choice B:

General anesthesia will numb your lower body and allow you to remain awake during the surgery. This is false because general anesthesia does not numb only a part of the body, but rather affects the whole body and brain. Numbing only a part of the body is called regional anesthesia, which involves injecting an anesthetic near a cluster of nerves to block pain signals from that area. Regional anesthesia can be used for some types of hysterectomies, but not for abdominal hysterectomy.

Choice C:

General anesthesia will block pain signals from reaching your brain and make you sleepy during the surgery. This is partially true but incomplete. General anesthesia does block pain signals from reaching your brain, but it also makes you unconscious, not just sleepy. You will not be aware of anything that is happening during the surgery or remember anything afterwards. General anesthesia also affects other functions of your body, such as breathing, blood pressure, and heart rate.

Choice D:

General anesthesia will relax your muscles and reduce your awareness of what is happening during the surgery. This is also partially true but incomplete. General anesthesia does relax your muscles and reduce your awareness, but it also makes you completely unconscious and unable to feel any pain. You will not have any memory of the surgery or be able to respond to any stimuli. General anesthesia also has other effects on your body, such as lowering your body temperature and slowing down your digestion.

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Question 5:

A nurse is reviewing the preoperative checklist of a client who is going to have a laparoscopic cholecystectomy. Which of the following items should be completed before transferring the client to the operating room?

A. Remove dentures, glasses, contact lenses, jewelry and nail polish. B. Administer a sedative or anxiolytic medication as prescribed. C. Mark the surgical site with an indelible marker. D. All of the above.

Answer and Explanation

Choice A:

Removing dentures, glasses, contact lenses, jewelry and nail polish is part of the physical preparation of the client before surgery. These items can interfere with the anesthesia, cause injury, or be lost during the procedure.

Choice B:

Administering a sedative or anxiolytic medication as prescribed is part of the preoperative medication of the client before surgery. These medications can help reduce anxiety, pain, nausea, and vomiting, and facilitate induction of anesthesia.

Choice C:

Marking the surgical site with an indelible marker is part of the patient identification and verification process before surgery. This helps prevent wrong-site, wrong-procedure, or wrong-person surgery by ensuring that the correct site is marked and confirmed by the client, surgeon, and nurse.

Choice D:

All of the above. All of these items should be completed before transferring the client to the operating room as part of the preoperative checklist. The checklist ensures that necessary documentation, admission assessment, physical preparation, and client education have been completed before the client enters the surgical suite.

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Question 6:

A nurse is evaluating a client's understanding of postoperative instructions after a total hip replacement surgery. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.).

A. "I will use a walker or crutches to avoid putting too much weight on my new hip.” B. "I will keep my legs crossed when I sit or lie down to prevent dislocation.” C. "I will avoid bending my hip more than 90 degrees when I get dressed or use the toilet.” D. "I will take antibiotics as prescribed to prevent infection.” E. "I will report any signs of bleeding, swelling, redness or drainage from my incision.”

Answer and Explanation

Choice A:

This statement is correct and does not indicate a need for further teaching. The client should use a walker or crutches to avoid putting too much weight on the new hip and prevent dislocation or damage to the prosthesis.

Choice B:

This statement is incorrect and indicates a need for further teaching. The client should not keep the legs crossed when sitting or lying down, as this can cause dislocation of the new hip joint. The client should keep the affected leg in abduction at all times.

Choice C:

This statement is correct and does not indicate a need for further teaching. The client should avoid bending the hip more than 90 degrees when getting dressed or using the toilet, as this can also cause dislocation of the new hip joint. The client should use assistive devices such as a long-handled reacher or a raised toilet seat.

Choice D:

This statement is correct and does not indicate a need for further teaching. The client should take antibiotics as prescribed to prevent infection, which can be a serious complication of hip replacement surgery. The client should also report any signs of fever, chills, or increased pain.

Choice E:

This statement is correct and does not indicate a need for further teaching. The client should report any signs of bleeding, swelling, redness or drainage from the incision, as these can also indicate infection or hematoma formation. The client should keep the incision clean and dry and change the dressing as instructed.

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Question 7:

The nurse is caring for a client who had spinal anesthesia for surgery on his right foot. Which assessment finding requires immediate intervention by the nurse?

A. The client reports numbness in his right leg. B. The client has a blood pressure of 90/60 mm Hg. C. The client complains of a headache when sitting up. D. The client has difficulty voiding after surgery.

Answer and Explanation

Choice A:

The client reports numbness in his right leg. This is not a cause for immediate intervention by the nurse, because numbness is an expected effect of spinal anesthesia. Spinal anesthesia blocks the nerve impulses from the lower extremities, lower abdomen, pelvic, and perineal regions, resulting in loss of sensation and movement.

Choice B:

The client has a blood pressure of 90/60 mm Hg. This is not a cause for immediate intervention by the nurse, because mild hypotension is a common side effect of spinal anesthesia. Spinal anesthesia causes vasodilation and decreases the sympathetic tone, leading to reduced blood pressure. The nurse should monitor the client's vital signs and fluid status, and administer vasopressors if needed.

Choice C:

The client complains of a headache when sitting up. This is a cause for immediate intervention by the nurse, because it may indicate a post-dural puncture headache (PDPH). PDPH is a complication of spinal anesthesia that occurs when the dura mater is punctured by the needle, causing cerebrospinal fluid (CSF) to leak and create a pressure gradient between the intracranial and spinal compartments. The nurse should assess the client's pain level, position the client flat or with a slight head elevation, administer analgesics and fluids, and notify the anesthesiologist.

Choice D:

The client has difficulty voiding after surgery. This is not a cause for immediate intervention by the nurse, because urinary retention is a common problem after spinal anesthesia. Spinal anesthesia affects the bladder function by inhibiting the micturition reflex and impairing the sensation of bladder fullness. The nurse should monitor the client's urine output, bladder distension, and fluid intake, and assist with catheterization if needed.

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Question 8:

The nurse is assisting with positioning a client for surgery in the lateral position. Which action by the nurse demonstrates proper technique?

A. Placing a pillow under the dependent axilla. B. Flexing both knees at a 90-degree angle. C. Aligning the shoulders directly over each other. D. Elevating the dependent arm on an arm board.

Answer and Explanation

Choice A:

Placing a pillow under the dependent axilla is a proper technique for lateral positioning because it helps to prevent brachial plexus injury by reducing the pressure on the neurovascular structures in the axilla. It also helps to maintain the alignment of the shoulder and prevent shoulder drop.

Choice B:

Flexing both knees at a 90-degree angle is not a proper technique for lateral positioning because it can cause excessive pressure on the knees and ankles, leading to nerve injury or skin breakdown. It can also impair venous return and increase the risk of deep vein thrombosis (DVT). Only the dependent leg should be flexed at the hip and knee, while the upper leg should be straight and supported by pillows between the legs.

Choice C:

Aligning the shoulders directly over each other is not a proper technique for lateral positioning because it can cause compression of the dependent shoulder and compromise the blood supply to the arm. It can also cause shoulder drop and brachial plexus injury. The lower shoulder should be pulled slightly forward and supported by a pad under the chest wall.

Choice D:

Elevating the dependent arm on an arm board is not a proper technique for lateral positioning because it can cause excessive abduction of the arm and stretch the brachial plexus. It can also interfere with surgical access to the thorax or kidney. Both arms should be supported on parallel arm boards with abduction less than 90 degrees.

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Question 9:

The nurse is reviewing the informed consent form with a client who is scheduled for surgery with regional anesthesia. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.).

A. "I will not be able to move or feel anything below my waist.” B. "I will have to stay awake during the surgery.” C. "I will need someone to drive me home after the surgery.” D. "I will have less risk of nausea and vomiting than with general anesthesia.” E. "I will have to fast for at least 8 hours before the surgery.”

Answer and Explanation

Choice A:

This statement is correct. Regional anesthesia blocks the sensation of pain and other sensations from a specific part of the body, such as below the waist for spinal or epidural anesthesia. The client will not be able to move or feel anything in the affected area during the surgery.

Choice B:

This statement is incorrect. Regional anesthesia does not require the client to stay awake during the surgery, unless the client prefers to do so. The client can also receive sedation or general anesthesia along with regional anesthesia, depending on the type and duration of the surgery and the client's preference.

Choice C:

This statement is incorrect. Regional anesthesia can have residual effects on the client's motor and sensory function, as well as blood pressure and heart rate, for several hours after the surgery. The client will need someone to drive them home after the surgery and monitor them for any signs of complications.

Choice D:

This statement is correct. Regional anesthesia has some advantages over general anesthesia, such as less risk of nausea and vomiting, less blood loss, less stress response, and better postoperative pain control.

Choice E:

This statement is correct. Regional anesthesia does not affect the client's ability to swallow or protect their airway, unlike general anesthesia. However, the client will still have to fast for at least 8 hours before the surgery to prevent aspiration of stomach contents in case general anesthesia or sedation is needed or administered.

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Question 10:

The circulating nurse notices that an incorrect sponge count has been reported by the scrub nurse during an abdominal surgery. What action should be taken by the circulating nurse?

A. Notify anesthesia personnel. B. Notify surgeon immediately. C. Notify risk management. D. Notify operating room supervisor.

Answer and Explanation

Choice A:

This is the correct answer. This is to prevent the risk of leaving a foreign object inside the patient, which can cause serious complications such as infection, abscess, bowel obstruction, or perforation.

Choice B:

This is incorrect. Notifying anesthesia personnel is not the priority action when an incorrect sponge count is reported. Anesthesia personnel are not responsible for counting or searching for sponges, and they cannot intervene in the surgical procedure without the surgeon's consent. The surgeon is the one who needs to be informed first, as they have the authority and ability to search the wound and decide whether to continue or stop the surgery.

Choice C:

This is incorrect. Notifying risk management is not the priority action when an incorrect sponge count is reported. Risk management is a department that deals with identifying, assessing, and minimizing potential hazards in health care settings. While it is important to report any adverse events or errors to risk management, this should be done after ensuring the patient's safety and resolving the issue. The priority is to notify the surgeon and search for the missing sponge.

Choice D:

This is incorrect. Notifying operating room supervisor is not the priority action when an incorrect sponge count is reported. The operating room supervisor is a person who oversees the daily operations of the surgical suite, such as staffing, scheduling, equipment, and supplies. While they may be involved in addressing any problems or conflicts that arise in the OR, they are not directly responsible for counting or searching for sponges, and they cannot interfere with the surgical procedure without the surgeon's consent. The priority is to notify the surgeon and search for the missing sponge.

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Question 11:

The scrub nurse is preparing for an emergency cesarean section for a client who has a positive HIV test result. The nurse plans care knowing that which of these precautions will be implemented?

A. Double gloving. B. Placing instruments in closed containers at completion of surgery. C. Wearing shoe covers in addition to personal protective equipment. D. Using instruments only from specially marked trays.

Answer and Explanation

Choice A:

Double gloving is a recommended precaution for health care workers who are exposed to blood or body fluids of clients who have a positive HIV test result. Double gloving can reduce the risk of needlestick injuries and transmission of HIV or other bloodborne pathogens.

Choice B:

Placing instruments in closed containers at completion of surgery is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Placing instruments in closed containers does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice C:

Wearing shoe covers in addition to personal protective equipment is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Wearing shoe covers does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice D:

Using instruments only from specially marked trays is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Using instruments only from specially marked trays does not protect the health care workers from exposure to blood or body fluids during surgery.

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Question 12:

A client who had surgery yesterday tells the nurse, "I don't want to get out of bed because it hurts too much.” Which responses by the nurse are appropriate? (Select all that apply.).

A. "I understand how you feel, but staying in bed can cause complications.” B. "You need to get out of bed at least three times a day to prevent blood clots.” C. "Let me give you some pain medication and then we can try getting up.” D. "Getting out of bed will help you heal faster and reduce your pain.” E. "Why don't you want to get out of bed? Are you afraid of something?”

Answer and Explanation

Choice A:

This response is not appropriate because it does not acknowledge the patient's pain or offer any pain relief. It also sounds dismissive and unsympathetic to the patient's feelings. A better response would be to empathize with the patient and explain the benefits and risks of early mobilization in a respectful way.

Choice B:

This response is not appropriate because it does not address the patient's pain or provide any pain relief. It also sounds demanding and authoritarian, which may increase the patient's anxiety and resistance. A better response would be to collaborate with the patient and set realistic and individualized goals for mobility.

Choice C:

This response is appropriate because it acknowledges the patient's pain and offers a solution to reduce it. It also shows respect for the patient's autonomy and readiness by suggesting rather than ordering to get up. It also implies that the nurse will assist and support the patient during the activity.

Choice D:

This response is appropriate because it provides positive reinforcement and education to the patient. It explains how early mobilization can enhance wound healing and decrease pain by improving blood circulation, preventing complications, and restoring function.

Choice E:

This response is not appropriate because it sounds accusatory and judgmental. It may make the patient feel defensive or guilty for expressing their pain or reluctance. A better response would be to explore the patient's concerns and fears in a non-threatening way and provide reassurance and information as needed.

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Question 13:

A nurse is caring for a patient who underwent surgery for appendicitis and has developed wound dehiscence with evisceration on postoperative day 3. What is the priority nursing intervention?

A. Covering the wound with sterile gauze moistened with normal saline. B. Placing the patient in low Fowler's position with knees bent. C. Calling for assistance and notifying the surgeon. D. Applying pressure to the wound edges.

Answer and Explanation

Choice A:

Covering the wound with sterile gauze moistened with normal saline is a correct nursing intervention for wound evisceration, but it is not the priority action. The priority is to get immediate help and inform the surgeon of the situation.

Choice B:

Placing the patient in low Fowler's position with knees bent is another correct nursing intervention for wound evisceration, as it reduces tension on the abdominal muscles and prevents further protrusion of the bowel. However, it is not the priority action either.

Choice C:

Calling for assistance and notifying the surgeon is the priority nursing intervention for wound evisceration, as this is a surgical emergency that requires prompt intervention to prevent complications such as infection, necrosis, or shock. The nurse should also monitor the patient's vital signs and prepare for possible surgery.

Choice D:

Applying pressure to the wound edges is an incorrect nursing intervention for wound evisceration, as it can cause further damage to the bowel and increase the risk of infection. The nurse should avoid touching or manipulating the wound or the bowel.

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Question 14:

A nurse is caring for a patient who had spinal surgery and is at risk for deep vein thrombosis (DVT). Which of the following nursing interventions is most effective in preventing DVT?

A. Applying sequential compression devices to the lower extremities. B. Massaging the calves and thighs gently. C. Elevating the foot of the bed by 15 degrees. D. Encouraging early ambulation and leg exercises.

Answer and Explanation

Choice A:

Applying sequential compression devices (SCDs) to the lower extremities is the most effective nursing intervention in preventing DVT in a patient who had spinal surgery and is at risk for DVT. SCDs are pneumatic devices that inflate and deflate around the legs to promote venous return and prevent stasis of blood, which can lead to clot formation.

Choice B:

Massaging the calves and thighs gently is not recommended for a patient who had spinal surgery and is at risk for DVT. Massaging the affected area can dislodge a clot and cause a pulmonary embolism, which is a life-threatening complication of DVT.

Choice C:

Elevating the foot of the bed by 15 degrees is not an effective nursing intervention in preventing DVT in a patient who had spinal surgery and is at risk for DVT. Elevating the foot of the bed can increase venous stasis and impair circulation, which can increase the risk of clot formation.

Choice D:

Encouraging early ambulation and leg exercises is an effective nursing intervention in preventing DVT in a patient who had spinal surgery and is at risk for DVT, but not as effective as applying SCDs. Early ambulation and leg exercises can improve blood flow and prevent venous stasis, but they may not be feasible or safe for some patients who had spinal surgery, depending on their level of injury and mobility.

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Question 15:

A nurse is reviewing discharge instructions with a client who had a laparoscopic cholecystectomy. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)

A. "I can resume my normal activities in a week.” B. "I can take acetaminophen for pain relief.” C. "I can shower tomorrow and pat my incisions dry.” D. "I can eat a low-fat diet for the first month.” E. "I can expect some drainage from my incisions.”

Answer and Explanation

Choice A:

This statement is correct and does not indicate a need for further teaching. The client can resume normal activities in a week after a laparoscopic cholecystectomy.

Choice B:

This statement is correct and does not indicate a need for further teaching. The client can take acetaminophen for pain relief after a laparoscopic cholecystectomy.

Choice C:

This statement is correct and does not indicate a need for further teaching. The client can shower the day after surgery and pat the incisions dry to prevent infection.

Choice D:

This statement is correct and does not indicate a need for further teaching. The client can eat a low-fat diet for the first month to avoid stimulating the gallbladder and causing pain.

Choice E:

This statement is incorrect and indicates a need for further teaching. The client should not expect any drainage from the incisions, as this could indicate infection or leakage of bile. The client should report any drainage to the provider immediately. A) “I can resume my normal activities in a week.” B) “I can take acetaminophen for pain relief.” C) “I can shower tomorrow and pat my incisions dry.” D) “I can eat a low-fat diet for the first month.” E) “I can expect some drainage from my incisions.”

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Question 16:

A nurse is monitoring a patient who had general anesthesia for a hernia repair. Which of the following findings indicate that the patient is at risk for hypothermia? (Select all that apply.).

A. Shivering. B. Tachycardia. C. Pallor. D. Diaphoresis. E. Hypotension.

Answer and Explanation

Choice A:

Shivering is a sign of hypothermia because it is the body's way of generating heat when the core temperature drops below normal. Shivering can be uncontrollable in mild hypothermia and may stop in moderate to severe hypothermia as the body conserves energy.

Choice B:

Tachycardia is not a sign of hypothermia. In fact, hypothermia can cause bradycardia, which is a slow heart rate, as the body tries to reduce heat loss through the blood vessels.

Choice C:

Pallor is a sign of hypothermia because it indicates reduced blood flow to the skin as the blood vessels constrict to preserve core temperature. Pallor can also be accompanied by cyanosis, which is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood.

Choice D:

Diaphoresis is a sign of hypothermia because it is the result of excessive sweating that can occur after exposure to cold or wet environments. Sweating can increase heat loss through evaporation and lower the body temperature further.

Choice E:

Hypotension is a sign of hypothermia because it reflects decreased cardiac output and blood pressure as the heart muscle becomes less efficient and responsive to stimuli. Hypotension can also lead to shock, organ failure, and death if not treated promptly.

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Question 17:

A client who had abdominal surgery reports feeling "a pop” in his incisional area followed by severe pain when he turned in bed earlier in his shift; he now reports feeling "wet” in his abdominal area under his gown and dressing. The nurse should:

A. Call for assistance and stay with client. B. Remove dressing to assess wound. C. Cover wound with sterile towels soaked in sterile saline. D. Assess vital signs.

Answer and Explanation

Choice A:

The nurse should call for assistance and stay with the client because the client is likely experiencing wound evisceration, which is a surgical emergency that requires immediate intervention. Wound evisceration is the protrusion of bowel through an abdominal incision, and it can occur 4 to 5 days postoperatively following an increase in strain on the incision, such as from turning, coughing, sneezing, or vomiting. Clients often report feeling something has "popped” or opened in the wound, followed by severe pain and a sensation of wetness. The nurse should not leave the client alone or attempt to reinsert the bowel.

Choice B:

The nurse should not remove the dressing to assess the wound because this could increase the risk of infection and further injury to the wound. The nurse should cover the wound with a nonadherent dressing moistened with warm sterile normal saline to protect the wound from contamination and drying. Removing the dressing could also cause more pain and bleeding to the client.

Choice C:

The nurse should not cover the wound with sterile towels soaked in sterile saline because this could cause maceration of the skin and increase the risk of infection. The nurse should use a nonadherent dressing moistened with warm sterile normal saline to prevent adherence to the wound and allow for drainage. Sterile towels could also be too bulky and heavy for the wound.

Choice D:

The nurse should not assess vital signs as the first action because this would delay the urgent care needed for the client. The nurse should call for assistance and stay with the client while covering the wound with a nonadherent dressing moistened with warm sterile normal saline. Assessing vital signs can be done after securing help and stabilizing the wound. Vital signs may show signs of shock, such as hypotension, tachycardia, tachypnea, and pallor. A) Call for assistance and stay with client. B) Remove dressing to assess wound. C) Cover wound with sterile towels soaked in sterile saline. D) Assess vital signs.

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Question 18:

The nurse is caring for a client who has just returned from surgery following an open reduction internal fixation (ORIF) of a fractured hip. The nurse should monitor for which of the following complications?

A. Fat embolism B. Pulmonary edema C. Deep vein thrombosis D. Myocardial infarction.

Answer and Explanation

Choice A:

Fat embolism is a possible complication of ORIF of a fractured hip. A fat embolism occurs when fat droplets from the bone marrow enter the bloodstream and block small blood vessels in the lungs, brain, or other organs. This can cause serious symptoms such as shortness of breath, chest pain, confusion, seizures, or coma. Fat embolism syndrome is more common with fractures of long bones such as the femur.

Choice B:

Pulmonary edema is not a likely complication of ORIF of a fractured hip. Pulmonary edema is a condition where fluid accumulates in the lungs, making it difficult to breathe. Pulmonary edema can be caused by heart failure, kidney failure, lung infections, or high altitude. It is not directly related to bone fractures or surgery.

Choice C:

Deep vein thrombosis (DVT) is a possible complication of ORIF of a fractured hip. DVT is a blood clot that forms in a deep vein, usually in the leg. DVT can cause pain, swelling, redness, or warmth in the affected area. DVT can also break off and travel to the lungs, causing a pulmonary embolism, which is a life-threatening emergency. DVT is more likely to occur after surgery or prolonged immobility.

Choice D:

Myocardial infarction (MI) is not a likely complication of ORIF of a fractured hip. MI is a heart attack that occurs when the blood supply to the heart muscle is interrupted, causing damage or death of the heart tissue. MI can be caused by coronary artery disease, which is the buildup of plaque in the arteries that supply the heart. MI can also be triggered by stress, physical exertion, or other factors. MI is not directly related to bone fractures or surgery. A) Fat embolism B) Pulmonary edema C) Deep vein thrombosis D) Myocardial infarction

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