Nokea
The client is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which finding indicates that the bladder irrigation is effective?
- A. The client reports minimal pain and discomfort.
- B. The urine appears clear and free of clots.
- C. The client has no signs of infection.
- D. The client is able to void independently.
Correct Answer: B
Rationale: The presence of clear urine free of clots is an indicator that the bladder irrigation is effective. This finding suggests that the irrigation is preventing clot formation and ensuring proper drainage, which is crucial after a TURP procedure. The client reporting minimal pain and discomfort (choice A) may be a positive sign but does not directly reflect the effectiveness of the bladder irrigation. The absence of infection signs (choice C) is important but not specific to evaluating the bladder irrigation. The client being able to void independently (choice D) is a good sign overall but does not specifically indicate the effectiveness of the bladder irrigation.
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A patient's neighbor is scheduled for elective surgery. The neighbor's provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest?
- A. Avoid the blood transfusion
- B. Donate autologous blood before the surgery
- C. Use a blood substitute
- D. Take antibiotics before the surgery
Correct Answer: B
Rationale: Donating autologous blood before surgery is an appropriate suggestion by the nurse. This process involves the patient donating their own blood before the surgery, which reduces the risk of infection from transfusions as the patient is receiving their own blood. Choice A is incorrect as avoiding the blood transfusion may not be feasible or safe in the context of expected blood loss during surgery. Choice C is not a common practice and may carry its own risks. Choice D is not directly related to reducing the risk of infection from a blood transfusion.
The charge nurse on the unit observes that one of the staff nurses is not using proper hand washing techniques. Which is the most appropriate initial approach to correct the behavior?
- A. Remind the nurse that proper hand washing prevents infection
- B. Discuss what the nurse knows about proper hand hygiene
- C. Provide a review of the hand washing policy
- D. Refer the nurse to the infection control nurse
Correct Answer: B
Rationale: The most appropriate initial approach to correct the behavior of improper hand washing by a staff nurse is to discuss what the nurse knows about proper hand hygiene. This approach helps in identifying any knowledge gaps the nurse may have and provides an opportunity to educate and correct the behavior. Option A is not the best choice as simply reminding the nurse about the importance of hand washing may not address the underlying issue of knowledge or technique. Option C, providing a review of the hand washing policy, may be necessary but is not the most immediate step to take. Option D, referring the nurse to the infection control nurse, is premature and may not be necessary if the issue can be resolved through education and communication first.
A client enters the emergency department unconscious via ambulance from the client's workplace. What document should be given priority to guide the direction of care for this client?
- A. The statement of client rights and the client self-determination act
- B. Orders written by the healthcare provider
- C. A notarized original of advance directives brought in by the partner
- D. The clinical pathway protocol of the agency and the emergency department
Correct Answer: C
Rationale: In this scenario, when the client is unconscious and unable to make decisions, a notarized original of advance directives brought in by the partner should be given priority to guide the direction of care. Advance directives provide legal documentation of the client's wishes regarding healthcare decisions in situations where they cannot express their preferences. The statement of client rights and the client self-determination act (Choice A) outlines general principles but does not provide specific guidance on the client's care. Orders written by the healthcare provider (Choice B) are important but may not reflect the client's preferences. Clinical pathway protocols (Choice D) are useful for standard care pathways but do not address individual client wishes.
A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement?
- A. Evaluate the stool samples for the presence of blood
- B. Assess for the presence of an impaction
- C. Determine which home remedies were used
- D. Obtain a list of prescribed medications
Correct Answer: B
Rationale: Assessing for impaction is crucial as it is a common cause of constipation and abdominal discomfort. In this scenario, the patient's symptoms of chronic constipation and no bowel movement for five days despite trying home remedies indicate a potential impaction that needs to be assessed. Evaluating stool samples for blood, determining the home remedies used, or obtaining a list of prescribed medications, while potentially relevant, are not as urgent as assessing for impaction in this situation.
A client who is receiving chemotherapy for cancer treatment is experiencing nausea and vomiting. What is the best intervention for the LPN/LVN to implement?
- A. Offer the client small, frequent meals.
- B. Provide antiemetic medication as prescribed.
- C. Encourage the client to drink clear liquids.
- D. Assist the client with oral care.
Correct Answer: B
Rationale: The best intervention for a client experiencing chemotherapy-induced nausea and vomiting is to provide antiemetic medication as prescribed. This medication helps in managing and reducing nausea and vomiting, providing relief to the client. Offering small, frequent meals (Choice A) may not address the underlying cause of the symptoms. Encouraging clear liquid intake (Choice C) may not be effective in controlling nausea and vomiting associated with chemotherapy. Assisting with oral care (Choice D) is important for overall comfort but may not directly address the symptoms of nausea and vomiting.