Nokea
The nurse is calculating the intake and output for a client who had a transurethral prostatectomy and is receiving continuous bladder irrigation at 175 mL/hr. The nurse empties 2300 mL of urine from the urinary drainage bag at the end of the 8-hour shift. How many mL should the nurse document as the client's net urine output for the shift? Record your answer using a whole number.
- A. 900 mL
Correct Answer: A
Rationale: Irrigation input = 175 mL/hr × 8 hr = 1400 mL. Total output = 2300 mL. Net urine output = 2300 mL - 1400 mL = 900 mL.
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The nurse is obligated to make a report for which situations? Select all that apply.
- A. Report to a client's employer that the client had a car crash while intoxicated
- B. Report to the authorities of a death by suicide on the unit
- C. Report to the client's spouse that the client has a reportable sexually transmitted disease
- D. Report to the hotline that an elderly client has suspicious bruising but denies caregiver abuse
- E. Report to the supervisor that a health care provider has the smell of alcohol on the breath
Correct Answer: B,D,E
Rationale: Reporting is mandatory for suicides, suspected elder abuse, and impaired providers. Reporting to employers or spouses violates confidentiality.
The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate?
- A. Retractions in the intercostal tissues of the thorax
- B. Chest pain aggravated by respiratory movement
- C. Cyanosis and mottling of the skin
- D. Rapid, shallow respirations
Correct Answer: A
Rationale: Retractions in the intercostal tissues of the thorax. Severe airway obstruction causes extreme intercostal retractions due to increased respiratory effort.
A parent calls the clinic about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse?
- A. Acetaminophen being given every 4 hours for fever
- B. Bismuth subsalicylate being used for nausea
- C. Ibuprofen being given every 6 hours for body aches
- D. Popsicles and gelatin desserts being used for hydration
Correct Answer: B
Rationale: Bismuth subsalicylate is contraindicated in children with viral infections due to Reye syndrome risk, requiring intervention. Other actions are appropriate.
The emergency department nurse is caring for a 70-year-old client with a history of type 2 diabetes mellitus who reports sudden-onset nausea, sweating, dizziness, and fatigue. The nurse should anticipate the initiation of which protocol?
- A. Food poisoning
- B. Influenza
- C. Myocardial infarction
- D. Stroke
Correct Answer: C
Rationale: Symptoms like nausea, sweating, dizziness, and fatigue in a 70-year-old with diabetes suggest myocardial infarction, requiring immediate cardiac protocol initiation.
The wife of a man who is diagnosed with angina pectoris asks the nurse how she would know if her husband had a heart attack rather than angina. What should the nurse include in the reply?
- A. Crushing chest pain not relieved by nitroglycerin is likely to be a heart attack.
- B. Epigastric pain relieved by antacids is likely to be angina.
- C. Chest pain that does not go down the left arm is usually angina.
- D. Chest pain not associated with activity or excitement is probably angina.
Correct Answer: A
Rationale: Myocardial infarction causes severe chest pain unresponsive to nitroglycerin, unlike angina, which typically resolves. Epigastric pain, arm radiation, or activity triggers are less definitive.