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A client is being discharged from the hospital to home with an indwelling urinary catheter after the surgical repair of the bladder after trauma. The nurse determines that the client understands the principles of catheter management to prevent complications if the client states to follow which instruction?
- A. Cleanse the perineal area with soap and water once a day.
- B. Keep the drainage bag lower than the level of the bladder.
- C. Limit fluid intake so that the bag will not become full so quickly.
- D. Coil the tubing and place it under the thigh when sitting to avoid tugging on the bladder.
Correct Answer: B
Rationale: Keeping the drainage bag lower than the bladder prevents urine backflow, reducing infection risk. The perineal area should be cleansed twice daily and after bowel movements. Adequate fluid intake is necessary to prevent infection, and coiling tubing under the thigh can obstruct drainage.
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A client has a prescription for ketoconazole. Which instruction should the nurse teach the client to follow while taking this medication?
- A. Avoid exposure to sunlight.
- B. Limit alcohol to 2 ounces per day.
- C. Take the medication with an antacid.
- D. Take the medication on an empty stomach.
Correct Answer: A
Rationale: The client should be taught that ketoconazole is an antifungal medication. The client should avoid exposure to sunlight because the medication increases photosensitivity. The client should avoid the concurrent use of alcohol because the medication is hepatotoxic. Antacids should be avoided for 2 hours after it is taken because gastric acid is needed to activate the medication. This medication should be taken with food or milk.
A client is preparing to undergo a cystoscopy for stones. Which of the following statements indicates that the client understands the procedure?
- A. I better drink a lot of fluid now because I won't be able to after the test.
- B. I will probably see a little blood when I urinate.
- C. I will be able to go home after 3 days in the hospital.
- D. I won't need any pain medicine; this probably will not hurt.
Correct Answer: B
Rationale: The correct answer is, 'I will probably see a little blood when I urinate.' During a cystoscopy, a scope is inserted into the client's bladder to inspect structures or remove objects like stones. This procedure is usually performed under local or general anesthesia. It is common for clients to experience a small amount of blood in their urine (hematuria) or have pink-colored urine after the procedure. The other choices are incorrect because drinking a lot of fluid before the test, staying in the hospital for 3 days, and assuming no pain will be experienced are not accurate statements related to a cystoscopy procedure.
A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the medication. What statement by the client indicates that the client understands the instructions?
- A. I will report a fever or sore throat to my doctor.
- B. Some joint pain is expected and is nothing to worry about.
- C. I must brush my teeth frequently to avoid damage to my gums.
- D. My urine may turn red in color, but this is nothing to be concerned about.
Correct Answer: A
Rationale: Carbamazepine is an anticonvulsant medication and is also used to alleviate the pain associated with trigeminal neuralgia. Agranulocytosis is an adverse effect of carbamazepine, and it places the client at risk for infection. If the client develops a fever or a sore throat, the primary health care provider should be notified. Unusual bruising and bleeding are also adverse effects of the medication, and they need to be reported to the primary health care provider if they occur.
The nurse has completed teaching with a hemodialysis client regarding the self-monitoring of the fluid status between hemodialysis treatments. The nurse determines that the client understands the information given if the client states the need to record which item(s) on a daily basis?
- A. Activity
- B. Pulse and respiratory rate
- C. Intake, output, and weight
- D. Blood urea nitrogen and creatinine levels
Correct Answer: C
Rationale: Recording daily intake, output, and weight helps monitor fluid status, ensuring no more than 0.5 kg weight gain per day between hemodialysis sessions. Activity, pulse, respiratory rate, and lab values are not daily client responsibilities.
The nurse is teaching a client with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation should the nurse use to best describe the reasoning for this therapy?
- A. Because of this dysrhythmia, blood backs up in the legs and puts you at risk for blood clots.
- B. This dysrhythmia decreases the volume of blood flowing from the heart, which can lead to blood clots forming in the brain.
- C. The antidysrhythmic medications you are taking cause blood clots as a side effect, so you need this medication to prevent them.
- D. Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which could then loosen and travel to the lungs or brain.
Correct Answer: D
Rationale: In atrial fibrillation, the quivering atria cause sluggish blood flow, leading to clot formation along the heart wall, which can dislodge and cause pulmonary or cerebral emboli. Options A, B, and C inaccurately describe the mechanism requiring anticoagulation.