A patient returns to your unit after a neck dissection. The surgeon placed a Jackson Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours you would notify the physician immediately for what?
A) Blood clots in the drainage
B) 300 cc. of milky or cloudy drainage
C) Spots of drainage on the dressings surrounding the drain
D) 120 cc. of serosanguinous drainage
Ans: B
Feedback: Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours. Excessive drainage may be indicative of a chyle fistula or hemorrhage.
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A pediatric nurse performs a physical examination on a neonate and notes a spinal lesion with the meninges protruding through the defect that contains spinal cord elements. The nurse documents which condition as being present?
A. Hydrocephalus B. Meningitis C. Meningocele D. Myelomeningocele E. Spina bifida occulta
The nursing students are studying disorders of the lips, gums, teeth, mouth and salivary glands. What group of people would the students learn is at high risk for parotitis?
A) School age B) Adolescents C) Elderly D) Middle-aged
A patient with a hordeolum (sty) asks what caused the disorder. What is the nurse's best response?
1. "This may be due to the dandruff on your scalp and eyebrows." 2. "This is possibly a side-effect of a medication you are taking." 3. "It is a result of eversion of the eyelid and associated with the aging process." 4. "It may be due to squinting when you are in the sun and not wearing sunglasses."
Patient calls the clinic to ask about taking a glucosamine-chondroitin supplement for arthritis. The nurse reviews the medication history and notes that there will be a concern for drug interactions if the patient is also taking medications for which disorder?
a. Type 2 diabetes mellitus
b. Hypothyroidism
c. Hypertension
d. Angina