A patient, who had a hysterectomy 2 days ago, reports tenderness in her left calf. The nursing assessment reveals the following: left calf 17.5", right calf 14", left thigh 32", right thigh 28", and a shiny, warm, and reddened left leg. Which of the following interventions should be given priority in the patient's plan of care? i. Maintain bedrest ii. Encourage ambulation TID iii. Apply bilateral antiembolism v. Apply right antiembolism stockings stockings vi. Apply warm moist heat as ordered iv. Encourage bilateral leg exercises

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Burns Pediatric Primary Care Test Bank Questions

Question 1 of 5

A patient, who had a hysterectomy 2 days ago, reports tenderness in her left calf. The nursing assessment reveals the following: left calf 17.5", right calf 14", left thigh 32", right thigh 28", and a shiny, warm, and reddened left leg. Which of the following interventions should be given priority in the patient's plan of care? i. Maintain bedrest ii. Encourage ambulation TID iii. Apply bilateral antiembolism v. Apply right antiembolism stockings stockings vi. Apply warm moist heat as ordered iv. Encourage bilateral leg exercises

Correct Answer: A

Rationale: The patient's symptoms and assessment findings suggest the presence of deep vein thrombosis (DVT), which is a potential complication following surgery such as a hysterectomy. The priority interventions in this case should focus on preventing the progression of DVT and reducing the risk of pulmonary embolism.

Question 2 of 5

Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. The mechanism of action of antimetabolites interferes with:

Correct Answer: D

Rationale: Antimetabolites interfere with the synthesis of nucleic acids, specifically RNA and DNA. By disrupting one or more stages of RNA and/or DNA synthesis, antimetabolites disrupt the normal cellular processes required for cell division and replication, ultimately leading to inhibition of cell proliferation. This makes them effective agents in targeting rapidly dividing cells, such as cancer cells, which rely heavily on nucleic acid synthesis for their rapid growth. The mechanism of action of antimetabolites is cell cycle-nonspecific, meaning they can affect cells at various stages of the cell cycle rather than being specific to a particular phase like M or S phase.

Question 3 of 5

Which of the ff suggestions should a nurse give breastfeeding mothers to prevent or eliminate mastitis and breast abscess? Choose all that apply

Correct Answer: D

Rationale: Keeping hands and breasts clean is crucial in preventing infections like mastitis and breast abscess. Proper hygiene practices can help reduce the risk of introducing harmful bacteria to the breast during breastfeeding. It is essential for breastfeeding mothers to wash their hands before each feeding session and ensure that the breast is clean before nursing.

Question 4 of 5

A male client is prescribed medications that depress thrombocytes. The nurse should monitor for which of the ff signs and symptoms in the client?

Correct Answer: C

Rationale: Thrombocytes, also known as platelets, play a crucial role in blood clotting. Medications that depress thrombocytes can lead to decreased clotting ability and an increased risk of bleeding. Therefore, monitoring for signs and symptoms of bleeding is essential. Bleeding gums and dark tarry stools are indicative of bleeding in the oral cavity and gastrointestinal tract, respectively, and are key indicators to watch for in a client taking medications that depress thrombocytes. Options A, B, and D are not directly related to the impact of thrombocyte depression on clotting function.

Question 5 of 5

Aling Maria, a 58-year old female, was admitted for the third time because of myxedema. Initial assessment by Nurse Mida should include symptoms of:

Correct Answer: C

Rationale: The symptoms of myxedema, which is a severe form of hypothyroidism, include lethargy, weight gain, slow speech, and decreased respiratory rate. Aling Maria being a 58-year old female who was admitted for the third time because of myxedema would likely present with these symptoms upon assessment by Nurse Mida. Other common symptoms of myxedema include cold intolerance, dry skin, hair loss, and brittle nails. It is important for Nurse Mida to identify these symptoms during the initial assessment to provide appropriate care and management for Aling Maria.

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