Medical surgical Exam 1 (NSG 123)

Correct Answer: D. Applying graduated compression stockings

Rationale:

Venous leg ulcers are primarily caused by chronic venous insufficiency (CVI), where the veins in the legs cannot effectively return blood to the heart, leading to increased pressure in the veins and poor oxygenation of the tissues. The most important intervention in managing venous leg ulcers is applying graduated compression stockings. These stockings help to improve venous return by applying pressure to the lower extremities, which promotes blood flow back to the heart, reduces edema, and facilitates ulcer healing. This intervention is widely recognized as the most effective in the management and prevention of venous leg ulcers.

Explanation of Incorrect Options:

A. Sclerotherapy:

Sclerotherapy involves the injection of a sclerosing agent into varicose veins to collapse them. While it is effective for varicose veins, it is not the primary treatment for venous leg ulcers. Sclerotherapy does not directly address the underlying chronic venous insufficiency or improve circulation in the affected area to promote ulcer healing.

B. Taking horse chestnut extract daily:

Horse chestnut extract has been suggested as a potential treatment for chronic venous insufficiency due to its anti-inflammatory properties and ability to improve venous tone. However, while it may provide some symptomatic relief, it is not considered a primary intervention for ulcer healing. The evidence supporting its effectiveness in healing venous ulcers is not as strong as the evidence supporting the use of compression stockings.

C. Using moist environment dressings:

Moist wound healing is an important aspect of caring for any type of wound, including venous ulcers, as it supports cell growth and reduces pain. While using moist dressings is beneficial for wound healing, compression therapy is the cornerstone of treatment for venous leg ulcers. Moist dressings should be used in conjunction with compression therapy for optimal healing, but they are not the most important intervention by themselves.

Summary:

The most important intervention in the healing and control of venous leg ulcers is applying graduated compression stockings. These stockings improve venous return, reduce edema, and promote ulcer healing. While moist dressings and therapies like sclerotherapy or horse chestnut extract may have complementary roles, compression therapy remains the primary treatment.

Correct Answer: B) Allergens and radiation

Rationale:

External factors that subject the skin to injury include physical, chemical, and environmental agents that can damage or weaken the skin's protective barrier.

Allergens: Cause irritation, inflammation, and allergic reactions (e.g., contact dermatitis from chemicals, pollen, or latex).Weaken skin integrity, making it more prone to injury.

Radiation: Ultraviolet (UV) radiation from the sun causes burns, DNA damage, and skin cancer. Medical radiation therapy can lead to radiation burns, increased skin sensitivity, and delayed wound healing.

Why the Other Options Are Incorrect:

A) Emaciation and infections 

Emaciation (extreme thinness) results in fragile skin, but it is an internal factor (related to nutrition and body condition). Infections occur when the skin is already compromised; they do not initially cause injury but worsen existing damage.

C) Radiation and emaciation

Radiation is external, but emaciation is an internal factor, making this answer partially incorrect.

D) Allergens and infections

Allergens are external irritants, but infections result from internal factors like weakened immunity or bacterial exposure. Infections are a consequence, not a primary cause, of skin injury.

Summary:

External factors include allergens and radiation, which directly damage the skin. Emaciation and infections are internal factors, affecting skin integrity indirectly.

Correct Answer: A. Impaired gas exchange

Rationale:

Pneumocystis jiroveci pneumonia (PJP) is a common opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS). The infection affects the lungs and severely impairs oxygen exchange. As a result, the priority nursing diagnosis for this patient is impaired gas exchange due to the compromised ability of the lungs to oxygenate the blood effectively. The symptoms of PJP often include hypoxia, difficulty breathing, and low oxygen saturation levels, all of which lead to impaired gas exchange. The nurse should focus on monitoring oxygen levels, administering oxygen as prescribed, and assisting with respiratory interventions to improve the patient's oxygenation status.

Why the Other Options Are Incorrect:

B. Impaired oral mucous membranes:

While oral mucosal changes may occur in patients with AIDS due to infections (e.g., candidiasis), it is not as critical a concern in this situation as impaired gas exchange. The priority in PJP is supporting respiratory function.

C. Imbalanced nutrition: Less than body requirements:

Nutritional support is always important in patients with AIDS, especially since many experience weight loss and malnutrition. However, in the context of PJP, respiratory issues take precedence over nutritional concerns. Once the patient’s oxygenation is stabilized, nutritional support can be more effectively addressed.

D. Activity intolerance:

While activity intolerance is a common issue for patients with respiratory infections, particularly in PJP, it is not the most urgent diagnosis. The immediate priority is to manage the impaired gas exchange and stabilize the patient's respiratory status.

Summary:

The highest priority nursing diagnosis for a patient with AIDS and P. jiroveci pneumonia is A. Impaired gas exchange. This diagnosis addresses the patient's immediate respiratory needs, which is critical in treating PJP. While oral mucous membrane issues, nutrition, and activity intolerance are relevant concerns, they are secondary to stabilizing the patient's respiratory function.

Correct Answer: B. Increasing my intake of red meat and dark green leafy vegetables will be important.

Explanation of the Correct Answer:

The statement "Increasing my intake of red meat and dark green leafy vegetables will be important" indicates the need for more teaching. While dark green leafy vegetables are a good source of vitamins and minerals, increasing the intake of red meat is not typically recommended for individuals with rheumatoid arthritis. Red meat is high in saturated fats, which may contribute to increased inflammation and exacerbate arthritis symptoms. A balanced diet with more plant-based foods, lean proteins, and omega-3 fatty acids (found in fish and flaxseeds) is usually advised to reduce inflammation and support overall health.

Why the Other Options Are Incorrect:

A. Scheduling frequent periods of rest in between activities will be necessary.

This statement is correct because rest is important for managing rheumatoid arthritis. Frequent periods of rest help prevent fatigue, reduce joint strain, and manage symptoms effectively.

C. I will limit activities involving joint movement as much as possible.

This statement is incorrect, but the need for further teaching is not as strong as the issue with increasing red meat intake. Limiting joint movement can lead to stiffness and decreased joint function. However, in the context of managing rheumatoid arthritis, it is crucial to balance rest with gentle, appropriate exercise to maintain joint mobility.

D. I will avoid drinking caffeinated liquids and heavy meals close to bedtime.

This statement is correct because avoiding caffeine and heavy meals before bed helps improve sleep quality, which can be disrupted by pain or discomfort associated with rheumatoid arthritis.

Summary:

The client needs more teaching regarding increasing red meat intake because red meat may contribute to inflammation, which could worsen rheumatoid arthritis symptoms. The other statements are correct as they involve appropriate strategies for managing the condition, including rest, maintaining joint movement, and promoting better sleep hygiene.

Correct Answer: C. in a prone or supine position with the foot of his bed elevated higher than his head.

Rationale:

Postural drainage is a technique used to help clear mucus from the lungs, and gravity plays a crucial role in facilitating this process. The goal is to position the patient in a way that allows the affected lung lobe to drain toward larger airways, where it can be more easily expectorated. For pneumonia in the right lower lobe, the prone or supine position with the foot of the bed elevated higher than the head is ideal. This positioning uses gravity to help drain the right lower lobe, which is located below the other lobes, allowing mucus to flow toward larger airways.

Why the Other Options Are Incorrect:

A. Semi-Fowler's position with knees bent:

This position, where the patient is propped up slightly with the knees bent, is typically used for comfort and to help patients with respiratory distress. It does not assist in draining the lower lobes, specifically the right lower lobe. Gravity is not fully utilized in this position for postural drainage.

B. Right side-lying position with the foot of the bed elevated:

While this position can be useful for some types of postural drainage, it does not efficiently drain the right lower lobe. Elevating the foot of the bed in this way may not fully encourage drainage of the lower lung areas as effectively as a prone or supine position with the foot elevated higher than the head.

D. Bent at the waist leaning slightly forward:

This position is generally used to help clear secretions from the upper lobes and airways, not for the lower lobes. The patient may find this helpful for upper airway drainage, but it is not effective for postural drainage of the right lower lobe.

Summary:

For postural drainage of the right lower lobe in a patient with pneumonia, the correct position is C. in a prone or supine position with the foot of the bed elevated higher than the head. This position uses gravity to help drain the affected lung lobe. Other options (A, B, and D) either do not effectively target the lower lobe or are intended for different purposes.

Correct Answer: A. 25 mL

Explanation of the Correct Answer:

First, determine the dose per administration. The total daily dose is 1 g/day divided into four doses.

1 g = 1000 mg, so 1000 mg ÷ 4 = 250 mg per dose.

Now, use the concentration available (500 mg in 50 mL) to calculate how much volume provides 250 mg.

Set up a proportion:

500 mg : 50 mL = 250 mg : X mL

Cross-multiply and solve:

500X = 12,500

X = 25 mL.

Therefore, the nurse should administer 25 mL per dose.

Why the Other Options Are Incorrect:

B. 50 mL

This option is incorrect because 50 mL would deliver 500 mg of cefazolin, which is double the prescribed single dose of 250 mg.

C. 100 mL

This option is incorrect because 100 mL would contain 1000 mg (1 g) of cefazolin, which is the total daily dose, not the amount for one divided dose.

D. 12.5 mL

This option is incorrect because 12.5 mL would deliver only 125 mg of cefazolin, which is half the required dose of 250 mg per administration.

Summary:

The nurse should administer 25 mL of cefazolin per dose. This correctly delivers 250 mg per dose based on the available concentration of 500 mg/50 mL. The other options would result in incorrect dosing, either too much or too little medication.

Correct Answer: D. Monoclonal antibody or Immunosuppressive agent

Explanation of the Correct Answer:

Systemic lupus erythematosus (SLE) is an autoimmune disorder that often requires medications to control inflammation and suppress immune system activity. Monoclonal antibodies and immunosuppressive agents are commonly used to treat SLE, particularly in severe cases. Monoclonal antibodies like belimumab are parenteral (injected) and are used to reduce disease activity in patients with SLE by targeting specific immune system components that are overactive in the disease. Immunosuppressive agents such as cyclophosphamide or azathioprine are also parenteral and work by suppressing the immune system to reduce inflammation.

Why the Other Options Are Incorrect:

A. Anticholinergic or Angiotensin-converting enzyme inhibitors

Anticholinergics are typically used for treating conditions like motion sickness or overactive bladder, and ACE inhibitors are used for hypertension and heart failure. Neither class of drugs is commonly used to treat SLE or decrease its disease activity, and these drugs are usually available in oral forms, not parenteral.

B. Antimalarial or Dopamine agonists

Antimalarial drugs, such as hydroxychloroquine, are used to treat SLE and can be taken orally, not parenterally. Dopamine agonists, on the other hand, are primarily used to treat Parkinson’s disease and conditions like prolactinomas, and they are not typically used to treat SLE.

C. Corticosteroid or Nonsteroidal anti-inflammatory drug

While corticosteroids and NSAIDs (such as ibuprofen) are commonly used to manage SLE symptoms, corticosteroids are generally administered orally or intravenously in severe cases, and NSAIDs are usually oral. However, this option does not specifically refer to the parenteral forms typically administered for disease-modifying effects in SLE.

Summary:

The correct answer is monoclonal antibodies or immunosuppressive agents, as these medications are specifically used in the treatment of systemic lupus erythematosus and are often administered parenterally. The other options either do not relate to SLE treatment or involve drugs typically given orally rather than by injection.

The correct answer is: "The client who is obese and had an open abdominal aortic aneurysm repair."

Explanation:

Wound dehiscence refers to the separation or opening of a surgical wound, which can occur when the tissues do not heal properly or when there is excessive strain on the surgical site. Several factors increase the risk of wound dehiscence, including:

Obesity: Individuals who are obese have a higher risk for wound complications, including dehiscence, due to increased abdominal pressure, impaired blood flow, and slower wound healing.

Type of surgery: An open abdominal aortic aneurysm repair is a major surgery with a larger incision and increased strain on the surgical site during recovery. The complexity and size of the incision contribute to a higher risk of dehiscence.

Why the other options are incorrect:

The older adult client who had the gallbladder removed laparoscopically: Laparoscopic surgery involves small incisions and tends to have a lower risk of wound dehiscence compared to open surgeries. While older adults may have a higher risk for general complications, laparoscopic procedures reduce the strain on the wound and generally promote better healing.

The pediatric client who had an open appendectomy: Although children may have unique considerations in healing, an open appendectomy does not carry as high of a risk for wound dehiscence as the combination of obesity and a major open surgery like an abdominal aortic aneurysm repair.

The client who had an exploratory laparoscopy: Like laparoscopic gallbladder removal, laparoscopic exploratory surgery involves small incisions, and the risk of wound dehiscence is lower compared to open abdominal surgeries. Additionally, laparoscopy generally leads to faster recovery times with fewer complications

Summary:

The client at the highest risk for wound dehiscence is the one who is obese and underwent an open abdominal aortic aneurysm repair due to the combination of obesity, the size of the incision, and the complexity of the surgery.

Correct Answer: "I should continue taking my prescribed anticoagulant up to the day of surgery."

Why this statement requires more teaching?

Anticoagulants, such as warfarin, heparin, or direct oral anticoagulants (DOACs) like rivaroxaban and apixaban, increase the risk of excessive bleeding during surgery. Most clients are advised to stop taking anticoagulants several days before surgery, depending on the medication and the patient’s individual risk factors. The nurse should educate the client on when to discontinue the anticoagulant based on the surgeon’s and healthcare provider’s recommendations. In some cases, alternative short-acting anticoagulants (e.g., low-molecular-weight heparin) may be used to bridge therapy before surgery.

Incorrect Answers and Explanations

"I should have just a sip of water with the medications approved for the morning of surgery." 

This statement is correct because some medications, such as antihypertensives or certain heart medications, are allowed the morning of surgery with a small sip of water. The surgeon or anesthesiologist provides specific instructions on which medications should be taken.

"I will wash with the shampoo you have provided me before surgery."

This statement is correct because preoperative skin cleansing with an antiseptic solution (e.g., chlorhexidine) helps reduce the risk of surgical site infections. Hospitals often provide clients with specific instructions on how to properly wash before surgery.

"I will practice good sleep habits prior to surgery."

This statement is correct because maintaining good sleep hygiene before surgery helps reduce stress, improves immune function, and supports recovery. Adequate rest can also contribute to better surgical outcomes.

Summary

The client requires more teaching regarding the continuation of anticoagulants before surgery, as these medications are typically discontinued to prevent excessive bleeding. The other statements reflect appropriate preoperative practices, including taking approved medications with a sip of water, preoperative cleansing, and maintaining good sleep habits.