Nokea
A client has returned from having a transurethral prostatectomy. Which finding should be reported to the doctor immediately?
- A. An hourly urinary output of 40-50 mL
- B. Bright red urine with many clots
- C. Dark red urine with few clots
- D. Requests for pain med every 4 hours
Correct Answer: B
Rationale: Bright red urine with many clots indicates significant bleeding post-prostatectomy, requiring immediate reporting. Normal output is 40-50 mL/hour, dark red urine with few clots is expected, and pain med requests are routine.
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The nurse manager has been using a block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will
- A. Improve the quality of care
- B. Decrease staff turnover
- C. Minimize the amount of overtime payouts
- D. Improve team morale
Correct Answer: D
Rationale: Nurses are more satisfied when opportunities exist for autonomy and control. Self-scheduling improves team morale by giving staff more control over their work schedules.
The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an appropriate finger food?
- A. Hot dog pieces
- B. Sliced bananas
- C. Whole grapes
- D. Popcorn
Correct Answer: B
Rationale: Sliced bananas. Finger foods should be bite-size pieces of soft food such as bananas. Hot dogs and grapes can accidentally be swallowed whole and-mile occlude the airway. Popcorn is too difficult to chew at this age and can irritate the airway if swallowed.
Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items?
- A. The client has complaints of not sleeping well for the past week
- B. The family wants to discontinue the home meal service, meals on wheels
- C. The urine in the client has been cloudy for the last 2 days
- D. The partner says the client has slower days every other day
Correct Answer: C
Rationale: Home health aides need to report diverse information to nurses through phone calls and documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs which require immediate action and follow-up. The color of the urine requires follow-up evaluation.
The nurse is caring for a client with a new colostomy. Which of the following client statements indicates a need for further teaching?
- A. I should change the pouch when it’s about one-third full.
- B. I should empty the pouch every morning.
- C. I should eat a high-fiber diet to prevent constipation.
- D. I should check the skin around the stoma for irritation.
Correct Answer: B
Rationale: Emptying the pouch every morning is a rigid schedule that does not account for individual bowel patterns; it should be emptied when one-third to one-half full. Options A, C, and D are correct: changing when one-third full prevents leaks, high-fiber diets promote regularity, and skin checks prevent breakdown.
The nurse is caring for a client with a history of myocardial infarction.
- A. Which instruction is most important for a client post-myocardial infarction?
- B. Avoid heavy lifting for 6 weeks.
- C. Take nitroglycerin only when chest pain occurs.
- D. Resume normal activity immediately.
- E. Monitor blood pressure weekly.
Correct Answer: A
Rationale: Avoiding heavy lifting for 6 weeks prevents cardiac strain during myocardial healing. Nitroglycerin is used for angina, gradual activity resumption is advised, and blood pressure monitoring is routine but secondary.