Nokea
A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?
- A. Have him drink several glasses of water
- B. Perform Crede's method on the bladder from the bottom to the top
- C. Assist him to stand by the side of the bed to void
- D. Wait 2 hours and have him try to void again
Correct Answer: C
Rationale: When a male is not able to use a urinal unassisted, the client should stand by the side of the bed to void. This is the most desirable position for normal voiding for male clients. Also, given his age, he most likely has some degree of prostate enlargement which may interfere with voiding.
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Which information is a priority for the nurse to reinforce to an older client after intravenous pyelography?
- A. Eat a light diet for the rest of the day
- B. Rest for the next 24 hours since the preparation and the test is tiring
- C. During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days
- D. Measure the urine output for the next day and immediately notify the health care provider if it should decrease
Correct Answer: D
Rationale: This information would alert to the complication of acute renal failure which may occur as a complication from the dye and the procedure. Renal failure occurs most often in elderly patients who are chronically dehydrated before the dye injection.
The nurse is caring for a client with uncontrolled hypertension. Which findings require immediate nursing action?
- A. lower extremity pitting edema
- B. rales
- C. jugular vein distension
- D. weakness in left arm
Correct Answer: D
Rationale: weakness in left arm. In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining three choices indicate mild fluid overload and are not medical emergencies.
The nurse learns that the hospitalized client has a history of chronic hepatitis C. Which precaution should the nurse plan to implement?
- A. Airborne
- B. Contact
- C. Droplet
- D. Standard
Correct Answer: D
Rationale: D: Standard precautions are sufficient for hepatitis C, which is transmitted via blood and body fluids. A, B, C are unnecessary as hepatitis C is not airborne or droplet-transmitted.
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. abdominal x-ray
- B. auscultation
- C. flushing tube with saline
- D. aspiration for gastric contents
Correct Answer: A
Rationale: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.
Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?
- A. Orthostatic hypotension is a common side effect
- B. Most antipsychotic drugs cause elevated blood pressure
- C. This provides information on the amount of sodium allowed in the diet
- D. It will indicate the need to institute antiparkinsonian drugs
Correct Answer: A
Rationale: Orthostatic hypotension is a common side effect. Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour after receiving medication. They should be advised to get up slowly, especially from a supine position.