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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. Discontinue infusing solution.
- B. Irrigate the catheter manually.
- C. Monitor catheter drainage.
- D. Decrease the flow rate.
Correct Answer: C
Rationale: Monitoring catheter drainage allows the nurse to assess the effectiveness of bladder irrigation and the presence of clot formation, ensuring adequate drainage.
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A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?
- A. Topical antifungal.
- B. Topical corticosteroids.
- C. Topical analgesics.
- D. Colloidal oatmeal based lotion.
Correct Answer: B
Rationale: Topical corticosteroids are commonly used to reduce inflammation and itching associated with psoriasis, controlling symptoms and promoting healing.
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
- A. Sip fluids with each meal.
- B. Chew slowly and thoroughly.
- C. Reduce intake of fatty foods.
- D. Eat small frequent meals.
Correct Answer: D
Rationale: Eating small frequent meals is crucial after gastric bypass surgery to prevent complications like dumping syndrome and manage portion sizes effectively.
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Avoid wearing tight fitting clothes.
- B. Minimize intake of spicy foods.
- C. Begin a smoking cessation program.
- D. Remain upright following meals.
Correct Answer: D
Rationale: Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter, minimizing reflux episodes.
A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Palpitations and shortness of breath.
- B. Bradycardia and constipation.
- C. Muscle cramping and dry, flushed skin.
- D. Lethargy and lack of appetite.
Correct Answer: A
Rationale: Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating excessive thyroid hormone levels, which could result from an overdose of levothyroxine.
The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
- A. Eating patterns of dietary intake.
- B. Activity level of bowel sounds.
- C. Level and amount of physical activity.
- D. Color and consistency of feces.
Correct Answer: A
Rationale: Eating patterns and dietary intake are crucial in managing chronic pancreatitis as certain foods can exacerbate symptoms. Identifying dietary triggers and making appropriate dietary modifications can help alleviate abdominal pain.