Question

A patient is on the surgical unit after a total abdominal hysterectomy. Which finding requires contacting the health care?

Answer 1

Correct Answers:

Urine output of 125 mL in the first 8 hours atter surgery

Rationale :

🚨 A urine output of only 125 mL over 8 hours is significantly below the expected minimum of 30 mL/hour and may indicate renal hypoperfusion, dehydration, urinary retention, or acute kidney injury.

🚨 After a total abdominal hysterectomy, the urinary system should be monitored closely due to the proximity of the surgical site to the bladder and ureters, making urinary complications a priority concern.

🚨 In contrast:

Mild incisional pain with coughing is expected post-op.

A 1-inch area of bloody drainage is minimal and typical within 24 hours.

Decreased bowel sounds are common post-anesthesia and not alarming in the first 24–48 hours.

🚨 The nurse should notify the healthcare provider immediately about low urine output to prevent further complications.

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Answer 2

Correct Answers:

Instructing the patient to avoid vigorous coughing, sneezing, and lifting

Rationale :

🧠 A transsphenoidal hypophysectomy involves removing the pituitary gland through the nasal or sinus route, placing the patient at risk for cerebrospinal fluid (CSF) leakage due to disruption of the dural layer at the skull base.

🧠 Coughing, sneezing, or lifting heavy objects can significantly increase intracranial pressure (ICP) and disrupt the surgical site, leading to CSF leaks or even meningitis.

🧠 Preventing straining maneuvers is essential postoperatively. The nurse should instruct the patient to:

Avoid straining during bowel movements

Suppress sneezing/coughing if possible

Avoid bending or lifting

🧠 While notifying the provider about nasal drainage is important, the best preventive action is teaching the patient behaviors to avoid increased ICP.

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Answer 3

Correct Answers:

Absence breath sounds in the left lower lobe.

Rationale :

🚨 Absent breath sounds in a lung field immediately after a thoracentesis may indicate a pneumothorax, which is a potentially life-threatening complication.

🚨 Thoracentesis involves removing fluid from the pleural space, and if the lung is punctured or collapses, air can enter the pleural space, leading to lung collapse.

🚨 Early signs include:

Sudden absence of breath sounds

Shortness of breath

Tachypnea or tachycardia

Tracheal deviation in severe cases

🚨 This finding demands immediate assessment and notification of the healthcare provider, along with preparing for a chest x-ray and possibly chest tube insertion.

🚨 The other options (pain rating of 4, mild fatigue, low-grade fever, or stable vitals) are expected or non-critical post-procedure findings.

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Answer 4

Correct Answers:

Cleaning the halo insertion sites with chlorhexidine
Administering oral medications as prescribed
Observing the halo insertion sites for signs of infection
Developing the nursing plan of care for the patient

Rationale :

✅ Cleaning the halo insertion sites with chlorhexidine

🔹 Pin site care is a routine nursing skill within the scope of LPN/LVN practice, especially when following established facility protocols.

🔹 Chlorhexidine is often used as the antiseptic of choice due to its effectiveness in reducing bacterial colonization.

🔹 The LPN/LVN should use sterile technique, avoid dislodging pins, and ensure all surrounding tissue is gently but thoroughly cleaned.

🔹 Routine cleaning helps prevent infection, one of the most common complications with external fixation devices.

🔹 The RN should periodically evaluate technique and outcomes to ensure safe and effective care.

✅ Administering oral medications as prescribed

💊 Medication administration is a standard part of LPN/LVN duties and includes oral, subcutaneous, and intramuscular medications (excluding high-risk IV pushes unless state law permits).

💊 The LPN/LVN can administer pain medications, antibiotics, or antispasmodics based on the patient's condition and provider orders.

💊 They should verify the "five rights" of medication administration: right patient, drug, dose, route, and time.

💊 They must document the administration, report any side effects or lack of effect to the RN, and follow up on the client’s comfort level if needed.

💊 The RN retains responsibility for evaluating the medication's effectiveness and overseeing adjustments.

✅Observing the halo insertion sites for signs of infection

🔍 LPNs/LVNs are trained to observe clinical signs of local infection, including redness, swelling, drainage, warmth, or pain around the pin sites.

🔍 Early identification and prompt reporting to the RN or provider are critical for preventing systemic infection or osteomyelitis.

🔍 LPNs/LVNs should also monitor for odor or looseness of the pin, which may signal deeper tissue involvement.

🔍 This observation supports continuity of care and reduces the risk of serious complications.

🔍 Although they observe, they do not diagnose—it is the RN’s role to interpret findings and initiate medical interventions.

✅ Checking the patient’s skin for pressure from the device

🩹 LPNs/LVNs are competent to perform routine skin assessments, especially in areas where devices or braces may cause pressure or breakdown.

🩹 The nurse should check under the halo vest and straps, ensuring there is adequate padding and no skin irritation or breakdown.

🩹 This is vital for immobile patients, who are at higher risk for pressure ulcers, particularly over bony prominences or beneath supportive equipment.

🩹 LPNs/LVNs can apply skin barrier creams, adjust padding (as permitted), and report any skin compromise to the RN for further intervention.

🩹 Consistent skin checks help prevent infection, delayed healing, and reduce hospital-acquired complications.

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Answer 5

Correct Answers:

Exercise for 20 minutes three times a week.

Rationale :

🚫 The recommendation to exercise for only 20 minutes three times a week is inadequate based on current cancer prevention guidelines and indicates the student nurse needs correction.

✅ The American Cancer Society recommends adults engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity activity per week, ideally spread throughout the week (e.g., 30 minutes, 5 days per week).

✅ Regular physical activity helps lower the risk of several cancers, including breast, colon, and endometrial cancers.

✅ The other statements—getting regular physical exams, limiting alcohol, and knowing the 7 warning signs of cancer—are all evidence-based and appropriate.

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Answer 6

Correct Answers:

Suction tubing
Oxygen mask
Side rail pads

Rationale :

Suction tubing

🔹 Maintains airway clearance: During or immediately after a seizure, patients may have excessive secretions or vomit, which can obstruct the airway. Suction is essential to prevent aspiration.

🔹 Supports breathing: Aspiration can lead to respiratory distress or pneumonia; having suction ready helps avoid these complications.

🔹 Required for emergency response: Status epilepticus is a medical emergency where immediate airway management is a priority. Suctioning helps stabilize the airway.

🔹 Prevents complications: Effective suctioning decreases the risk of hypoxia and reduces the need for intubation.

🔹 Nursing priority: Having suction equipment nearby is part of seizure precautions and demonstrates preparedness for neurological emergencies.

Oxygen mask

🔸 Improves oxygenation: Seizures can reduce oxygen levels due to impaired breathing. Supplemental oxygen ensures tissue perfusion.

🔸 Postictal support: After a seizure, patients may be drowsy or confused with shallow breathing. An oxygen mask helps stabilize oxygen saturation.

🔸 Prevents brain hypoxia: Prompt oxygen delivery is crucial to prevent further neurological injury, especially in status epilepticus.

🔸 Immediate availability: Oxygen should be at the bedside for quick access if signs of respiratory compromise appear.

🔸 Promotes recovery: Oxygen therapy can reduce the duration and severity of postictal symptoms.

Side rail pads

🔻 Prevents injury: Padding protects the patient from head trauma, fractures, or bruises caused by striking bed rails during a seizure.

🔻 Part of standard seizure precautions: Hospitals require seizure-prone patients to have padded side rails to reduce injury risk.

🔻 Promotes safe environment: Padded rails ensure a safe setting while maintaining accessibility for care.

🔻 Reduces nurse intervention time: With rails padded in advance, nurses can focus on other emergency responses during a seizure.

🔻 Especially important for recurrent seizures: Patients with a history of status epilepticus are at high risk for repeated episodes, so protective measures must be in place.

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Answer 7

Correct Answers:

Intercostal muscle retractions are present

Rationale :

🟡 Signs of respiratory distress: Intercostal retractions indicate that the patient is using accessory muscles to breathe, a hallmark of significant airway obstruction and increased work of breathing.

🟡 Indicates severe asthma exacerbation: This physical sign suggests the attack may be progressing to a critical stage, requiring urgent intervention such as bronchodilators, steroids, or possibly intubation.

🟡 Airflow limitation: Retractions occur when the patient has difficulty moving air in and out of the lungs, which can lead to hypoxia if not addressed immediately.

🟡 Priority for escalation: Of all the findings, this one demands immediate provider notification because it reflects imminent respiratory compromise rather than just a history or mild symptoms.

🟡 Emergency-level response: The presence of retractions may also correlate with dropping oxygen saturations, which should be addressed with supplemental oxygen and rapid medication administration.

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Answer 8

Correct Answers:

Observing the pupils when the patient focuses on a close object and then on a distant object.

Rationale :

🔵 Accommodation reflex involves observing how the pupils adjust to near and far objects, a key test for cranial nerve II (optic) and III (oculomotor) function.

🔵 When a patient shifts gaze from a distant object to a near object, the pupils should constrict, and the eyes should converge. This demonstrates that the lens is adjusting to focus.

🔵 This is part of the PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation) assessment, essential for checking neurological and visual integrity.

🔵 This test also evaluates the ciliary muscle and lens function, indicating if the eyes can adapt for visual acuity at different distances.

🔵 Option A is the only choice that tests accommodation directly by assessing pupil reaction to changing focal distances.

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Answer 9

Correct Answers:

A breast nodule that is I cm in size, nontender, and fixed.

Rationale :

🟢 Fixed and nontender nodules are concerning signs for malignancy and require immediate further evaluation. A non-mobile (fixed) mass suggests possible invasion into surrounding tissues, a hallmark of breast cancer.

🟢 A nontender lump is more suspicious than a painful one, as malignant tumors are typically painless in early stages.

🟢 The size (1 cm) does not eliminate concern—early detection of small, nonmobile, and hard masses is critical in improving cancer outcomes.

🟢 Clinical signs like immobility, firm consistency, and lack of tenderness increase suspicion for malignancy and necessitate a diagnostic mammogram, ultrasound, or biopsy.

🟢 Other findings like cyclical tenderness or rubbery mobility often suggest benign breast changes like fibrocystic disease, but a fixed nodule warrants urgent follow-up.

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Answer 10

Correct Answers:

Respirations are 34 breath/min.

Rationale :

🟠 A respiratory rate of 34/min indicates tachypnea, suggesting that the patient is experiencing significant respiratory distress and increased work of breathing. This is a critical clinical sign that should be immediately reported.

🟠 Clients with COPD already have compromised gas exchange; a rapid increase in respiratory rate can signal impending respiratory failure, especially if accessory muscles are used or mental status changes.

🟠 Persistent tachypnea can lead to fatigue, hypoxemia, and hypercapnia, potentially requiring advanced airway support or changes to the oxygen delivery system.

🟠 The other findings (e.g., barrel chest, hyperresonance, decreased lung expansion) are typical chronic signs in COPD, but not acutely life-threatening like severe tachypnea.

🟠 Early recognition and reporting of this finding allows for prompt intervention, such as adjusting oxygen therapy, administering bronchodilators, or initiating non-invasive ventilation.

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Nur3317 Human Needs II Exam 2

No.

1 :
A patient is on the surgical unit after a total abdominal hysterectomy. Which finding requires contacting the health care?

2 :
The nurse is caring for a patient who underwent transsphenoidal hypophysectomy to treat acromegaly. Which is the best nursing action to prevent leakage of cerebrospinal fluid?

3 :
The nurse assesses a patient with lung cancer immediately after a thoracentesis. Which new finding requires the most immediate action by the nurse?

4 :
A patient with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device and multiple pins in place. When caring for this patient, the nurse may assign which actions to the LPN/LVN? Select 4 appropriate interventions.

5 :
The student nurse is discharging a patient and providing education on cancer prevention and early detection. Which statement by the student indicates a need for intervention by the nurse?

6 :
A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patients assigned room? Select All That Apply

7 :
The nurse assesses a patient who is having an acute asthma attack in the emergency department Which finding is most important to report to the primary provider?

8 :
When performing an eye examination, the nurse will assess for accommodation by doing which of the following?

9 :
Which assessment finding in a 36-yrold patient is most indicative of a need for further evaluation?

10 :
The nurse assesses a patient with chronic obstructive pulmonary disease (COPO) who has been admitted after increasing dyspnea over the past 2 days. Which finding is most important for the nurse to report to the health care provider?

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Nur3317 Human Needs II Exam 2

No.

1 : A patient is on the surgical unit after a total abdominal hysterectomy. Which finding requires contacting the health care?

2 : The nurse is caring for a patient who underwent transsphenoidal hypophysectomy to treat acromegaly. Which is the best nursing action to prevent leakage of cerebrospinal fluid?

3 : The nurse assesses a patient with lung cancer immediately after a thoracentesis. Which new finding requires the most immediate action by the nurse?

4 : A patient with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device and multiple pins in place. When caring for this patient, the nurse may assign which actions to the LPN/LVN? Select 4 appropriate interventions.

5 : The student nurse is discharging a patient and providing education on cancer prevention and early detection. Which statement by the student indicates a need for intervention by the nurse?

6 : A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patients assigned room? Select All That Apply

7 : The nurse assesses a patient who is having an acute asthma attack in the emergency department Which finding is most important to report to the primary provider?

8 : When performing an eye examination, the nurse will assess for accommodation by doing which of the following?

9 : Which assessment finding in a 36-yrold patient is most indicative of a need for further evaluation?

10 : The nurse assesses a patient with chronic obstructive pulmonary disease (COPO) who has been admitted after increasing dyspnea over the past 2 days. Which finding is most important for the nurse to report to the health care provider?

1 :
A patient is on the surgical unit after a total abdominal hysterectomy. Which finding requires contacting the health care?

2 :
The nurse is caring for a patient who underwent transsphenoidal hypophysectomy to treat acromegaly. Which is the best nursing action to prevent leakage of cerebrospinal fluid?

3 :
The nurse assesses a patient with lung cancer immediately after a thoracentesis. Which new finding requires the most immediate action by the nurse?

4 :
A patient with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device and multiple pins in place. When caring for this patient, the nurse may assign which actions to the LPN/LVN? Select 4 appropriate interventions.

5 :
The student nurse is discharging a patient and providing education on cancer prevention and early detection. Which statement by the student indicates a need for intervention by the nurse?

6 :
A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patients assigned room? Select All That Apply

7 :
The nurse assesses a patient who is having an acute asthma attack in the emergency department Which finding is most important to report to the primary provider?

8 :
When performing an eye examination, the nurse will assess for accommodation by doing which of the following?

9 :
Which assessment finding in a 36-yrold patient is most indicative of a need for further evaluation?

10 :
The nurse assesses a patient with chronic obstructive pulmonary disease (COPO) who has been admitted after increasing dyspnea over the past 2 days. Which finding is most important for the nurse to report to the health care provider?