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A nurse assesses a client 2 hours after TURP. What indicates a complication?
- A. Clear urine output
- B. Burgundy-colored urine output
- C. Mild pain at the incision site
- D. Temperature of 98.6°F
Correct Answer: B
Rationale: The correct answer is B: Burgundy-colored urine output. This indicates a complication post-TURP due to potential bleeding. Clear urine output (A) is normal. Mild pain at the incision site (C) is expected. Temperature of 98.6°F (D) is within normal range.
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A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?
- A. I may eat 10 ounces of lean protein each day
- B. I will limit my sodium intake.
- C. I will increase my intake of fruits and vegetables.
- D. I will avoid fried foods and processed meats.
Correct Answer: A
Rationale: The correct answer is A: "I may eat 10 ounces of lean protein each day." This statement indicates a need for further teaching because consuming 10 ounces of lean protein daily may lead to excessive protein intake, which can strain the kidneys and potentially worsen hypertension. Clients with hypertension should limit protein intake and focus on lean sources in moderation. Choices B, C, and D are correct as they align with a heart-healthy diet by limiting sodium intake, increasing fruits and vegetables, and avoiding fried foods and processed meats, respectively.
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
- A. Defibrillation
- B. Administer oxygen
- C. Call for help
- D. Start chest compressions
Correct Answer: A
Rationale: The correct answer is A: Defibrillation. Ventricular fibrillation is a life-threatening arrhythmia that requires immediate defibrillation to restore the heart's normal rhythm. Defibrillation is the priority as it is the most effective intervention to treat ventricular fibrillation and increase the chance of survival. Administering oxygen (B) is important but not the priority over defibrillation. Calling for help (C) should be done after initiating defibrillation. Starting chest compressions (D) should only be done if defibrillation is not immediately available or unsuccessful.
A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
- A. Serous
- B. Sanguineous
- C. Serosanguineous
- D. Purulent
Correct Answer: C
Rationale: The correct answer is C: Serosanguineous. This type of drainage is a mixture of clear (serous) and red (sanguineous) fluids, indicating a normal stage of wound healing. The clear fluid suggests minimal inflammation, while the red fluid indicates presence of blood. Serous drainage alone is typically clear and watery without any blood. Sanguineous drainage is bright red and indicates fresh blood. Purulent drainage is thick, opaque, and yellowish-green, suggestive of infection. Therefore, in this scenario, the observation of watery red drainage best fits the description of serosanguineous drainage.
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
- A. Establish the ability to communicate effectively.
- B. Increase mobility to a normal level.
- C. Promote independent living without assistance.
- D. Restore full visual function.
Correct Answer: A
Rationale: The correct answer is A: Establish the ability to communicate effectively. For a client who had a left hemispheric CVA, the left hemisphere is responsible for language and speech functions. Therefore, focusing on establishing effective communication is crucial in the rehabilitation program. It targets the specific deficits caused by the CVA and aims to improve the client's quality of life. Increasing mobility to a normal level (B) is important but may not be the priority in this case. Promoting independent living without assistance (C) is a broad goal that may encompass various aspects beyond communication. Restoring full visual function (D) is not directly related to a left hemispheric CVA.
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
- A. Atropine
- B. Epinephrine
- C. Magnesium
- D. Sodium bicarbonate
Correct Answer: A
Rationale: Rationale: Atropine is the correct answer because it is the first-line medication for symptomatic bradycardia. It works by blocking the parasympathetic nervous system, increasing heart rate. Epinephrine is used for cardiac arrest, not bradycardia. Magnesium is for torsades de pointes, not bradycardia. Sodium bicarbonate is for metabolic acidosis, not bradycardia.