The nurse is monitoring a patient who had an emergency appendectomy today. Which of the following findings should be reported to the physician immediately?
a. Pain at the operative site
b. Absence of bowel sounds
c. Abdomen rigid on palpation
d. 3-cm spot of bloody drainage on dressing
ANS: C
With peritonitis, a life-threatening complication, abdominal rigidity is present. The physician should be notified promptly for treatment orders.
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The client is 90 minutes postoperative after shoulder surgery and the Hemovac drain contains 400 ml of serosanguinous fluid since surgery. Which should the nurse do first?
1. Collaborate with the surgeon. 2. Monitor the Hemovac drainage. 3. Irrigate drain with sterile fluid. 4. Attach a larger Hemovac drain.
The partner of a client at 16 weeks' gestation accompanies her to the clinic. The partner tells the nurse that the baby just doesn't seem real to him, and he is having a hard time relating to his partner's fatigue and food aversions
Which statement would be best for the nurse to make? 1. "If you would concentrate harder, you'd be aware of the reality of this pregnancy." 2. "My husband had no problem with this. What was your childhood like?" 3. "You might need professional psychological counseling. Ask your physician." 4. "Many men feel this way. Feeling the baby move in a few weeks will help make it real to you."
A charge nurse (nurse manager for the unit) is working in a skilled nursing facility (SNF). What is the duty of the charge nurse?
A) Assist manager in establishing training protocols for staff nurses. B) Have 24-hour responsibility for the unit. C) Consult the physician before taking necessary actions during emergencies. D) Teach staff members how to check the crash carts.
A patient is diagnosed with a middle ear infection. Which portion of the patient's airway is affected?
A. Oropharynx B. Laryngopharynx C. Nasopharynx D. Nares