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A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with 0.9% sodium chloride 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 clears clots, maintaining catheter patency and preventing obstruction post-TURP.
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A client receives a prescription for 1 L of lactated Ringers to be infused IV over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)
- A. 125 mL/hr
Correct Answer: A
Rationale: Calculation: 1000 mL ÷ 8 hours = 125 mL/hr, ensuring accurate infusion rate.
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?
- A. Latent hepatitis C.
- B. Nephrotic syndrome history.
- C. Type 2 diabetes mellitus.
- D. Crohn's disease with colectomy.
Correct Answer: D
Rationale: Crohn's with colectomy contraindicates peritoneal dialysis due to altered abdominal anatomy, increasing infection risk.
The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?
- A. Get an influenza vaccine every year as soon as available.
- B. Using salt, herbs, and spices will Improve the flavor of foods.
- C. Restrict alcoholic beverages to no more than 1-2 per week.
- D. Eat a protein snack 30 minutes before any exercise workout.
Correct Answer: B
Rationale: Using herbs and spices reduces reliance on sugars and fats, supporting glycemic control in diabetes.
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
- A. Reduce intake of fatty foods.
- B. Chew slowly and thoroughly.
- C. Eat small frequent meals.
- D. Sip fluids with each meal.
Correct Answer: C
Rationale: Small, frequent meals prevent stomach pouch stretching and dumping syndrome, optimizing nutrient absorption.
The healthcare provider prescribes penicillin 200,000 units IM for a client with pneumonia. The available vial is labeled, 'Penicillin 500,000 units/mL'. How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
- A. 0.4 mL
Correct Answer: A
Rationale: Calculation: 200,000 units ÷ 500,000 units/mL = 0.4 mL, ensuring accurate dosing.