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A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?
- A. Light pink urine
- B. Occasional suprapubic cramping
- C. Minimal drainage into the urinary collection bag
- D. Complaints of the feeling of pulling on the urinary catheter
Correct Answer: C
Rationale: In a client with an indwelling catheter and continuous bladder irrigation post TURP, minimal drainage into the urinary collection bag should be reported to the health care provider. This finding could indicate a blockage in the catheter or a complication that requires immediate attention. Light pink urine (choice A) is expected due to bladder irrigation. Occasional suprapubic cramping (choice B) is common post-TURP. Complaints of the feeling of pulling on the urinary catheter (choice D) may indicate discomfort but do not suggest an urgent issue like a potential blockage.
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The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Assess nail beds for color and refill
- B. Assess for postoperative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Postoperative arrhythmias are a common and potentially serious complication after cardiac surgery, making them a priority to monitor. Assessing for postoperative arrhythmias takes precedence over other assessments like checking nail beds for color and refill, auscultating for pulmonary congestion, or monitoring peripheral pulses as arrhythmias can have immediate and severe implications for the child's health.
A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse recommend the family members to omit?
- A. Boiled rice
- B. Italian bread
- C. Broiled salmon filet
- D. Pickled beets
Correct Answer: D
Rationale: The correct answer is D, Pickled beets. Pickled foods often contain high levels of sodium, which should be avoided in a low-sodium diet. Boiled rice, Italian bread, and broiled salmon filet are generally lower in sodium compared to pickled beets, making them more suitable choices for a client on a low-sodium diet.
Which of these clients, all in the terminal stage of cancer, is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th-grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent alertness
Correct Answer: D
Rationale: The correct answer is D, a preschooler with intermittent alertness. This client may not have the cognitive ability to effectively use a PCA pump due to their age and alertness level. They may not understand how to self-administer the analgesia. Choices A, B, and C are more appropriate candidates for PCA as they are likely to have better comprehension and ability to operate the PCA pump compared to a preschooler with intermittent alertness.
A nurse is assisting with the development of strategies to prevent foodborne illnesses for a community group. The nurse should plan to include which of the following recommendations? (Select one that doesn't apply).
- A. Avoid unpasteurized dairy products.
- B. Keep cold food temperatures below 4.4°C (40°F).
- C. Discard leftovers after 48 hours.
- D. Wash raw vegetables thoroughly in clean water.
Correct Answer: C
Rationale: The correct answer is C. Discarding leftovers after 48 hours is not an effective recommendation to prevent foodborne illnesses. Leftovers should actually be discarded within 2 hours if they have been at room temperature. Choices A, B, and D are all effective strategies to prevent foodborne illnesses: avoiding unpasteurized dairy products reduces the risk of harmful bacteria, keeping cold food temperatures below 4.4°C (40°F) inhibits bacterial growth, and washing raw vegetables thoroughly removes contaminants.
A client with diabetes mellitus has a blood glucose level of 350 mg/dL. Which of these actions should the nurse take first?
- A. Administer insulin as ordered
- B. Encourage the client to drink fluids
- C. Notify the healthcare provider
- D. Recheck the blood glucose level in 30 minutes
Correct Answer: A
Rationale: Administering insulin as ordered is the priority action when a client with diabetes mellitus has a blood glucose level of 350 mg/dL. Insulin helps to lower the high blood glucose level and prevent complications such as diabetic ketoacidosis. Encouraging the client to drink fluids may be beneficial but does not address the immediate need to lower the blood glucose level. Notifying the healthcare provider and rechecking the blood glucose level can be important steps but should come after administering insulin to address the high glucose level promptly.