Nokea
A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following indicate that the client has developed a complication after the cystoscopy?
- A. Dizziness.
- B. 2. skills.
- C. Pink-tinged urine.
- D. Bladder spasms.
Correct Answer: D
Rationale: Bladder spasms post-cystoscopy indicate a complication, often due to irritation or trauma to the bladder lining, requiring medical attention. Pink-tinged urine is expected, and dizziness may relate to other causes.
You may also like to solve these questions
A client undergoing a bilateral adrenalectomy has postoperative orders for hydromorphone hydrochloride (Dilaudid) 2 mg to be given subcutaneously every 4 hours as needed for pain. The medication is administered in relatively small doses primarily because it is:
- A. Less likely to cause dependency in small doses.
- B. Less irritating to subcutaneous tissues in small doses.
- C. As potent as most other analgesics in larger doses.
- D. Excreted before accumulating in toxic amounts in the body.
Correct Answer: C
Rationale: Hydromorphone is a potent opioid, effective in small doses, reducing the need for larger doses that increase side effect risks.
A client with diabetes mellitus comes to the clinic for a regular 3-month follow-up appointment. The nurse notes several small bandages covering cuts on the client's hands. The client says, 'I'm so clumsy. I'm always cutting my finger cooking or burning myself on the iron.' Which of the following responses by the nurse would be most appropriate?
- A. Soak small wounds in isopropyl alcohol.'
- B. Keep all cuts clean and covered.'
- C. Why don't you have your children do the cooking and ironing?'
- D. You really should be fine as long as you take your daily medication.'
Correct Answer: B
Rationale: Keeping cuts clean and covered prevents infection, a significant risk in diabetes due to poor wound healing.
The nurse should tell the client to do which of the following when teaching the client about taking oral glucocorticoids?
- A. Take your medication with a full glass of water.'
- B. Take your medication on an empty stomach.'
- C. Take your medication at bedtime to increase absorption.'
- D. Take your medication with meals or with an antacid.'
Correct Answer: D
Rationale: Taking glucocorticoids with meals or an antacid reduces gastrointestinal irritation, a common side effect.
The nurse in the infusion center is caring for a 27-year-old male.
Item 1 of 1
• Nurses' Notes
1401: Orders received for PRBC transfusion. 20-gauge peripheral vascular access device (VAD) started right antecubital space. Blood return was observed, and was flushed with 10 mL of sodium chloride (normal saline) without resistance. The client denied any discomfort at the VAD. Sterile dressing was applied to the VAD. The client was provided verbal education regarding the potential blood transfusion reactions. The client verbalized understanding.
1430: PRBC unit retrieved from blood bank. Vital signs were obtained prior to starting blood transfusion: 99.0° F (37.2° C) P 78, RR 18, BP 130/86, pulse oximetry reading 97% on room air.
1439: Verified and checked client ID and blood product with another RN. Initiated PRBC transfusion via y-type tubing. Will remain with the client for 15 minutes to observe for any potential transfusion-related reaction.
1454: The client denied any manifestations of a transfusion reaction. Vital signs: 99.5°F (37.5°C) P 75, RR 18, BP 132/85, pulse oximetry reading 96% on room air. Increased rate of PRBC transfusion.
1520: The client alerted RN to come to their bedside, reporting pain and discomfort at their VAD. VAD was swollen and cool to the touch.
• Orders
• Infuse 1 unit of packed red blood cells
• Medical History
• Sickle cell anemia
• Depression
The nurse reviews the clinical data and prepares to take action following the 1520 nursing note entry. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.
- A. pause the transfusion and discontinue the vascular access device,discontinue the packed red blood cell transfusion and return it to the blood bank
,start a new 20-gauge vascular access device in the opposite extremity,pause the transfusion obtain an order for acetaminophen - B. febrile transfusion reaction,infiltration at the vascular access device
hemolytic transfusion reaction,circulatory overload - C. discomfort and swelling at vascular access site,hemoglobin and hematocrit,temperature,blood pressure
Correct Answer:
Rationale: The nurse should monitor the discomfort and swelling at the VAD site. Pausing the transfusion, elevating the extremity, and applying a compress should alleviate the discomfort and swelling.
The nurse will need to monitor the client's hemoglobin and hematocrit to determine the efficacy of the PRBC transfusion. Generally, one unit of PRBCs will raise the hemoglobin by 1 g/dL.
It is inappropriate for the nurse to monitor the client's temperature as it pertains to infiltration. The client's temperature is not relevant in managing infiltration.
The blood pressure does not require monitoring because it does not show evidence of circulatory overload.
When administering I.V. midazolam hydrochloride (Versed) the nurse should?
- A. Assess the blood pressure.
- B. Monitor the pulse oximeter.
- C. Encourage slow, deep breaths.
- D. Explain relaxation techniques.
Correct Answer: B
Rationale: Midazolam can cause respiratory depression, so monitoring the pulse oximeter is essential to ensure adequate oxygenation during administration.