Nokea
A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?
- A. light, pink urine
- B. occasional suprapubic cramping
- C. minimal drainage into the urinary collection bag
- D. reports of the feeling of pulling on the urinary catheter
Correct Answer: C
Rationale: Options A, B, and D are expected complaints after this procedure. Option C needs to be reported immediately since minimal urinary drainage puts the client at risk for bladder rupture.
You may also like to solve these questions
An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
- A. administer the medication in 2 separate injections
- B. give the medication in the dorsal gluteal site
- C. call to get a smaller volume ordered
- D. check with pharmacy for a liquid form of the medication
Correct Answer: A
Rationale: administer the medication in 2 separate injections. Intramuscular injections should not exceed a volume of 1 ml for small children. Medication doses exceeding this volume should be split into 2 separate injections of 1.0 ml each. In adults the maximum intramuscular injection volume is 5 ml per site.
A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that
- A. such fantasies can gratify unconscious wishes or prepare for anticipated future events
- B. detaching or dissociating in this way postpones painful feelings
- C. converting or transferring a mental conflict to a physical symptom can lead to conflict within the partnership
- D. isolating the feelings in this way reduces conflict within the client and with others
Correct Answer: A
Rationale: such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes.
Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent episodes of alertness
Correct Answer: D
Rationale: A preschooler with intermittent episodes of alertness. A preschooler is most likely of these clients to have difficulty with the use or understanding of a PCA pump. This very young child lacking a normal level of consciousness would not benefit from the use of a PCA pump.
The HCP prescribes metronidazole 0.5 g orally three times daily for the client with an infection. The label states that each tablet is 250 mg. How many tablets should the nurse prepare to administer for one dose?
Correct Answer: 2
Rationale: 0.5 g = 500 mg; 500 mg/ 250 mg/tablet = 2 tablets per dose.
The nurse educator is focusing on the prevention of infection. Place an X on the illustration that displays the best measure to prevent infection when caring for clients on a nursing unit?
- A. infection_1.PNG
- B. infection_2.PNG
- C. infection_3.PNG
- D. infection_4.PNG
- E. infection_5.PNG
Correct Answer: A
Rationale: A: Hand hygiene is the most effective measure to prevent infection transmission. Other measures like isolation or gloves are situational, but hand washing is universally critical.