Nokea
A 64-year-old male client is admitted to the hospital with benign prostatic hypertrophy (BPH). The client has a history of adult onset diabetes mellitus and hypertension. He is scheduled to undergo a resection of the prostate. The most serious symptom that may accompany BPH is:
- A. acute urinary retention.
- B. hesitancy in starting urination.
- C. increased frequency of urination.
- D. decreased force of the urinary stream.
Correct Answer: A
Rationale: Acute urinary retention is a symptom of BPH, is serious, and requires urgent medical attention. Hesitancy in starting urination is a symptom of BPH, but it is not serious or life-threatening. Increased frequency of urination is a symptom of BPH, but it is not serious or life-threatening. Decreased force of the urinary stream is due to an obstruction, but it is not serious or life-threatening.
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Which tubes drain gastric contents (select all that apply)?
- A. T-tube
- B. Hemovac
- C. Nasogastric tube
- D. Indwelling catheter
Correct Answer: D
Rationale: Nasogastric and gastrointestinal tubes drain gastric contents effectively.
A post-anesthesia care unit nurse is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give the highest priority to?
- A. Arterial blood gases
- B. Urinary output
- C. Chest tube drainage
- D. Pain level
Correct Answer: A
Rationale: The correct answer is A: Arterial blood gases. This is the highest priority assessment for a client post-thoracotomy and lobectomy as it helps monitor the client's oxygenation status and acid-base balance, crucial after thoracic surgery. ABGs provide immediate information on the client's respiratory function, detecting any respiratory complications early on. The other options, B: Urinary output, C: Chest tube drainage, and D: Pain level, are important assessments but not as critical as monitoring the client's oxygenation status post-thoracic surgery. Urinary output is important for renal function, chest tube drainage for monitoring for any bleeding or air leakage, and pain level for comfort, but none of these directly assess the client's respiratory status and potential complications.
Identify the specific component of acquiring cultural competence reflected in creating a safe environment in which collection of relevant cultural data can be obtained during the health history and physical examination.
- A. Cultural skill
- B. Cultural encounter
- C. Cultural awareness
- D. Cultural knowledge
Correct Answer: A
Rationale: Creating a safe environment involves using cultural skills to gather accurate and meaningful cultural data during assessments.
What changes are seen in the skin during shock?
- A. Increased urine output
- B. Edema
- C. Hypertension
- D. Hypernatremia
Correct Answer: B
Rationale: Edema occurs due to excess fluid accumulation in the interstitial spaces, commonly seen in conditions like heart failure and kidney disease.
A client is postoperative, and a nurse is developing a plan of care. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
- A. Perform range-of-motion exercises
- B. Place suction equipment at the bedside
- C. Encourage the use of an incentive spirometer
- D. Administer an expectorant
Correct Answer: C
Rationale: The correct answer is C: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications by promoting deep breathing and preventing atelectasis. A: Range-of-motion exercises do not directly prevent pulmonary complications. B: Placing suction equipment is important but does not prevent pulmonary complications. D: Administering an expectorant helps with mucus clearance but does not prevent pulmonary complications as effectively as using an incentive spirometer.