Nokea
A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine:
- A. Should not be there on the second day
- B. Will stop when the Foley catheter is removed
- C. Is normal and he need not be concerned about it
- D. Can be removed by irrigating the bladder
Correct Answer: C
Rationale: Some hematuria is usual for several days after surgery. The client should not be concerned about it unless it increases.
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The physician has ordered Dilantin (phenytoin) 100 mg intravenously for a client with generalized tonic clonic seizures. The nurse should administer the medication:
- A. Rapidly with an IV push
- B. With IV dextrose
- C. Slowly over 2-3 minutes
- D. Through a small vein
Correct Answer: C
Rationale: Phenytoin must be administered slowly (over 2-3 minutes) to prevent cardiovascular complications like hypotension or arrhythmias. It should not be mixed with dextrose or given rapidly.
A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?
- A. I'm getting this shot so that my baby won't develop antibodies against my blood, right?'
- B. I understand that if my baby is Rh positive I'll be getting another one of these injections.'
- C. This shot should help to protect me in future pregnancies if this baby is Rh positive, like my husband.'
- D. This shot will prevent me from becoming sensitized to Rh-positive blood.'
Correct Answer: A
Rationale: RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. RhoGAM prevents maternal sensitization to Rh-positive blood.
The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
- A. Apply a clean dressing to protect the wound.
- B. Cover the exposed viscera with a sterile saline gauze.
- C. Gently replace the abdominal contents.
- D. Cover the area with a petroleum gauze.
Correct Answer: B
Rationale: Exposed viscera should be covered with sterile saline-soaked gauze to keep them moist and prevent infection until surgical repair. Replacing contents or using non-sterile/petroleum dressings is unsafe.
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort decreases when he:
- A. Avoids eating
- B. Rests in a recumbent position
- C. Eats a meal or snack
- D. Sits upright after eating
Correct Answer: C
Rationale: Duodenal ulcers cause pain relieved by eating due to buffering of gastric acid. Pain worsens when the stomach is empty. Resting or sitting upright does not directly relieve symptoms.
A vaginal exam of a laboring client reveals that the fetus is at 0 station. This assessment means that:
- A. The fetus has not descended into the birth canal.
- B. The fetus is in a transverse lie.
- C. The fetus is level with the ischial spines.
- D. The fetus is at increased risk for precipitate delivery.
Correct Answer: C
Rationale: A 0 station means the presenting part of the fetus is level with the ischial spines indicating engagement in the pelvis. It does not indicate a lack of descent transverse lie or immediate risk of precipitate delivery.