Nokea
A client returns from surgery after having a suprapubic prostatectomy. Upon assessing the client, the nurse notes that his urine is bright red with many clots. Which of the following nursing actions is most appropriate?
- A. Check the client's vital signs and notify the physician.
- B. Check whether the continuous irrigation is working properly.
- C. Recognize that this is a normal finding after surgery and continue post-op care.
- D. Apply traction on the catheter and notify the physician.
Correct Answer: B
Rationale: Bright red urine with clots suggests a need to check the continuous bladder irrigation system to ensure it is functioning to prevent clot obstruction.
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Based on knowledge of cultural diversity, the nurse knows that obtaining a CBC will be most distressing for the client who is:
- A. Asian
- B. African-American
- C. Latino
- D. Native American
Correct Answer: D
Rationale: Some Native American cultures believe blood removal weakens the body or spirit, making a CBC distressing. Other groups typically do not have this belief.
A client with myxedema should be prescribed which diet?
- A. A diet low in fats
- B. A diet high in carbohydrates
- C. A diet high in sugars
- D. A diet low in salt
Correct Answer: B
Rationale: Myxedema (hypothyroidism) slows metabolism, so a high-carbohydrate diet provides energy to support metabolic needs.
The nurse is caring for a client with Cushing's syndrome. The nurse should carefully assess the client for signs of:
- A. Hypoglycemia
- B. Infection
- C. Hypovolemia
- D. Hyperinsulinemia
Correct Answer: B
Rationale: Cushing's syndrome causes immunosuppression, increasing infection risk . Hypoglycemia , hypovolemia , and hyperinsulinemia are not primary concerns.
A client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client?
- A. A private room with contact and droplet precautions
- B. A private room with negative airflow and contact and airborne precautions
- C. A private room with positive airflow and airborne precautions
- D. A semi-private 2-bed room with standard precautions
Correct Answer: B
Rationale: Disseminated shingles in immunocompromised clients requires contact and airborne precautions due to varicella-zoster virus transmission risk. A private room with negative airflow prevents spread. Droplet or standard precautions are insufficient, and positive airflow is inappropriate.
The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?
- A. The injury is expected to heal quickly because of thin periosteum.'
- B. In some instances the result is a retarded bone growth.'
- C. Bone growth is stimulated in the affected leg.'
- D. This type of injury shows more rapid union than that of younger children.'
Correct Answer: B
Rationale: An epiphyseal (growth) plate fracture in a 7 year-old often results in retarded bone growth. The leg often will be different in length than the uninjured leg.