During a surgical procedure, the nurse notices a sudden decrease in the patient's oxygen saturation on the monitor. What immediate action should the nurse take?

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Question 1 of 9

During a surgical procedure, the nurse notices a sudden decrease in the patient's oxygen saturation on the monitor. What immediate action should the nurse take?

Correct Answer: A

Rationale: The correct immediate action is to inform the surgeon and anesthesiologist (Choice A) because a sudden decrease in oxygen saturation during surgery is a critical situation that requires prompt attention from the entire surgical team. The surgeon and anesthesiologist need to be made aware of the situation so that they can assess the patient's condition and make any necessary adjustments to the surgical procedure or anesthesia delivery. Increasing the flow rate of oxygen (Choice B) may help temporarily but does not address the underlying cause of the oxygen desaturation. Checking the endotracheal tube placement (Choice C) is important but may not be the immediate priority in this critical situation. Assessing the patient's respiratory status (Choice D) is important but should be done after informing the surgeon and anesthesiologist to ensure coordinated and timely interventions.

Question 2 of 9

Which of the following cell types is primarily responsible for presenting antigens to T cells during the immune response?

Correct Answer: C

Rationale: The correct answer is C: Macrophages. Macrophages are antigen-presenting cells that engulf pathogens and present their antigens to T cells, initiating an immune response. They express major histocompatibility complex (MHC) molecules necessary for T cell recognition. B cells also present antigens but primarily to B cells for antibody production. NK cells are involved in killing infected cells, not antigen presentation. Eosinophils are mainly involved in allergic responses and defense against parasites, not antigen presentation.

Question 3 of 9

What a patient has bleeding after surgery the PACU nurse, expects which color if coming from the arterial source?

Correct Answer: B

Rationale: The correct answer is B: Bright red and spurts with the heartbeat. This type of bleeding indicates arterial bleeding, which is oxygen-rich blood coming directly from the arteries. Arterial bleeding is bright red in color due to the high oxygen content and spurts with the heartbeat as it is under higher pressure. This rapid spurting is characteristic of arterial bleeding and requires immediate attention to control the bleeding source. Choices A, C, and D are incorrect because they describe characteristics of venous bleeding, not arterial bleeding. Venous bleeding is dark in color, flows slowly, and generally oozes as it is oxygen-depleted blood returning to the heart. Therefore, the correct answer is B based on the specific characteristics of arterial bleeding.

Question 4 of 9

A patient presents with severe headache, photophobia, and neck stiffness. On examination, there is nuchal rigidity and positive Kernig and Brudzinski signs. Which of the following neurological conditions is most likely responsible for these symptoms?

Correct Answer: C

Rationale: The correct answer is C: Meningitis. The patient's symptoms of severe headache, photophobia, neck stiffness, nuchal rigidity, and positive Kernig and Brudzinski signs are classic signs of meningitis. Meningitis is an inflammation of the meninges surrounding the brain and spinal cord, leading to these specific neurological symptoms. Migraine headache (A) typically presents with a throbbing headache, nausea, and sensitivity to light and sound, but does not typically cause neck stiffness or positive meningeal signs. Cluster headache (B) is characterized by severe unilateral headache with autonomic symptoms like tearing or nasal congestion, but does not typically cause neck stiffness or positive meningeal signs. Subarachnoid hemorrhage (D) presents with sudden severe headache often described as "the worst headache of my life," and may cause neck stiffness, but typically does not present with photophobia or positive meningeal signs like Kernig and Brudzinski signs.

Question 5 of 9

Which of the following statements is INCORRECT of collaboration in a health care settings?

Correct Answer: D

Rationale: The correct answer is D because interprofessional collaboration and multidisciplinary collaboration are not interchangeable terms. Interprofessional collaboration involves professionals from different disciplines working together to provide comprehensive care, while multidisciplinary collaboration involves professionals from various disciplines working alongside each other but not necessarily working together in a coordinated manner. This distinction is crucial in healthcare settings to ensure effective teamwork and patient-centered care. A: Trust and respect are core values of a collaborative organization - This statement is correct because trust and respect are essential for effective collaboration in healthcare settings. B: A shared vision is essential for collaboration in any health care operations - This statement is correct as a shared vision helps align team members towards common goals. C: Successful conflict resolution can help collaborative teams overcome differences - This statement is correct as resolving conflicts constructively can strengthen team dynamics and improve collaboration.

Question 6 of 9

A patient with a history of multiple myeloma demonstrates hypogammaglobulinemia. Which of the following immunoglobulin classes is most likely to be deficient in this patient?

Correct Answer: B

Rationale: The correct answer is B: IgA. In multiple myeloma, there is a proliferation of abnormal plasma cells, leading to a decrease in normal antibody production. IgA is the most abundant immunoglobulin in mucosal secretions and plays a crucial role in mucosal immunity. Therefore, a deficiency in IgA is common in patients with multiple myeloma. IgG is the most abundant immunoglobulin in the blood and is typically less affected in multiple myeloma. IgM is the first antibody produced in response to an infection and is less likely to be deficient in this case. IgE is primarily involved in allergic responses and is not typically affected in multiple myeloma.

Question 7 of 9

A postpartum client presents with severe abdominal pain, nausea, and vomiting. Which nursing action is most appropriate?

Correct Answer: C

Rationale: In a postpartum client who presents with severe abdominal pain, nausea, and vomiting, it is crucial to assess for signs of peritonitis or surgical abdomen. These signs may include rebound tenderness, guarding, rigidity, and fever. Peritonitis is a serious condition that may require immediate surgical intervention. Administering antiemetic medication, encouraging clear fluids, or providing a heating pad may not address the underlying cause of the symptoms and delay appropriate treatment. Assessing for signs of peritonitis or surgical abdomen is crucial for prompt identification and management of the client's condition.

Question 8 of 9

A woman in active labor is experiencing precipitous labor with rapid cervical dilation and descent of the fetal presenting part. What maternal complication should the nurse anticipate?

Correct Answer: A

Rationale: Precipitous labor is characterized by rapid cervical dilation and descent of the fetal presenting part, leading to a shortened labor duration of less than 3 hours. This rapid progression can increase the risk of maternal complications, such as postpartum hemorrhage. Postpartum hemorrhage is defined as excessive bleeding of more than 500 ml after vaginal delivery or more than 1000 ml after cesarean delivery. The rapid delivery in precipitous labor can result in inadequate uterine contractions after delivery, leading to poor uterine tone and potential postpartum hemorrhage due to uterine atony. Therefore, the nurse should anticipate postpartum hemorrhage as a potential maternal complication in a woman experiencing precipitous labor.

Question 9 of 9

A patient with a history of congestive heart failure is prescribed furosemide. Which electrolyte imbalance is the patient at risk for developing with furosemide therapy?

Correct Answer: B

Rationale: Step 1: Furosemide is a loop diuretic that works in the ascending loop of Henle to inhibit sodium and chloride reabsorption. Step 2: Inhibition of sodium reabsorption leads to increased water and electrolyte excretion, including potassium. Step 3: Increased potassium excretion can lead to hypokalemia, which is a common side effect of loop diuretics like furosemide. Step 4: Hypokalemia can be dangerous, especially in patients with congestive heart failure, as it can worsen cardiac function and lead to arrhythmias. Step 5: Therefore, patients with a history of congestive heart failure prescribed furosemide are at risk for developing hypokalemia due to increased potassium excretion.

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