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A client arrives at the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Decrease the flow rate.
- B. Irrigate the catheter manually.
- C. Discontinue infusing solution.
- D. Monitor catheter drainage.
Correct Answer: B
Rationale: Manual irrigation dislodges blood clots, ensuring catheter patency and preventing urinary obstruction.
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A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse's priority intervention?
- A. Obtain a sputum sample.
- B. Arrange transport for radiographic imaging.
- C. Move the patient into airborne isolation.
- D. Collect specimens for blood cultures.
Correct Answer: C
Rationale: Symptoms suggestive of tuberculosis require immediate airborne isolation to prevent transmission.
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
- A. Lower back pain and hypotension.
- B. Delayed painful rash with urticaria.
- C. Acute rhinitis and nasal stuffiness.
- D. Arthritic joint changes and chronic pain.
Correct Answer: A
Rationale: Lower back pain and hypotension are indicative of an acute ABO incompatibility reaction, which can lead to severe complications like hemolysis or shock, requiring immediate reporting and intervention.
An elderly patient is admitted with an acute onset of diverticulitis, and intravenous antibiotic therapy is started. What should the nurse do next?
- A. Elevate the head of the bed.
- B. Initiate a bowel prep protocol for surgery.
- C. Educate the patient on increasing dietary fiber.
- D. Maintain the patient's NPO status.
Correct Answer: D
Rationale: Maintaining NPO status rests the bowel, promoting healing during acute diverticulitis.
A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication does the nurse anticipate being prescribed by the healthcare provider?
- A. Morphine.
- B. Oxycodone.
- C. Hydromorphone.
- D. Fentanyl.
Correct Answer: A
Rationale: Morphine is typically prescribed for myocardial infarction symptoms to relieve pain and reduce cardiac workload.
The healthcare provider prescribes diagnostic tests for a patient whose chest x-ray indicates pneumonia. Which diagnostic test should the nurse prepare the patient for?
- A. Computerized tomography (CT) of the chest.
- B. Arterial blood gases (ABG).
- C. Sputum culture and sensitivity.
- D. Blood cultures.
Correct Answer: C
Rationale: A sputum culture and sensitivity test identifies the causative organism of pneumonia, guiding appropriate antibiotic therapy.