Nokea
A client returning from the postanesthesia care unit after transurethral resection of the prostate (TURP) has bladder irrigation running via a 3-way Foley catheter. The nurse should notify the primary health care provider if which color of urine is noted in the urinary drainage bag?
- A. Pale pink
- B. Bright red
- C. Dark pink
- D. Tea-colored
Correct Answer: B
Rationale: Bright red bleeding should be reported because it could indicate complications related to active bleeding. If the bladder irrigation is infusing at a sufficient rate, the urinary drainage will be pale pink. A dark pink color (sometimes referred to as punch-colored) indicates that the speed of the irrigation should be increased. Tea-colored urine is not seen after TURP but may be noted in the client with renal failure or other renal disorders.
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When witnessing an adult client's signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply.
- A. That there was adequate disclosure of information.
- B. That the client understood the information.
- C. That there was voluntary consent on the client's part.
- D. That the client has full awareness of the potential complications.
- E. That the client's relative, spouse or legal guardian was present.
Correct Answer: A,B,C,D
Rationale: Informed consent requires adequate disclosure, client understanding, voluntary consent, and awareness of complications. A relative's presence is not mandatory unless the client is incapacitated.
A client is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse implement to safely administer the blood?
- A. Keep the blood refrigerated on the nursing unit until ready to administer.
- B. Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction.
- C. Do not infuse blood that has been hanging for more than 6 hours.
- D. Administer the blood quickly to prevent wasting it if the client develops a fever.
Correct Answer: B
Rationale: Staying with the client for the first 15 minutes is critical to monitor for acute transfusion reactions, which are most likely to occur early.
Older adults with known cardiovascular disease must balance which of the following measures for optimum health?
- A. Diet, exercise, and medication.
- B. Stress, hypertension, and pain.
- C. Mental health, diet, and stress.
- D. Social events, diet, and smoking.
Correct Answer: A
Rationale: Diet, exercise, and medication are critical for managing cardiovascular disease, as they address risk factors like cholesterol, physical fitness, and blood pressure control, directly impacting heart health.
The nurse monitors the client for a hypoglycemic reaction, knowing that NPH insulin peaks in approximately how many hours following administration?
- A. 1 hour
- B. 2 to 3 hours
- C. 4 to 12 hours
- D. 16 to 24 hours
Correct Answer: C
Rationale: NPH is an intermediate-acting insulin with a peak time in 4 to 12 hours. The remaining options describe periods of time that are either too short or too long.
Which of the following is NOT an essential minimal component of the teaching that occurs prior to getting an informed consent?
- A. The purpose of the proposed treatment or procedure
- B. The expected outcomes of the proposed treatment or procedure
- C. Who will perform the treatment or procedure
- D. When the procedure or treatment will be done
Correct Answer: D
Rationale: Essential components of informed consent include the purpose , expected outcomes , and who will perform the procedure . The specific timing is not a required minimal component.