Nokea
A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse?
- A. True urinary output of 50ml/hr
- B. Lower abdominal tenderness
- C. Blood urine output with clots
- D. Urine leaking around the meatus
Correct Answer: D
Rationale: Urine leaking around the meatus may indicate catheter displacement or obstruction, requiring immediate attention to prevent complications.
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The nurse determines that a client who arrives in the preoperative holding area before surgery is allergic to bananas. Which action should the nurse implement prior to taking the client into the operative area?
- A. Replace latex-containing devices in the OR with alternate synthetic materials
- B. Administer an antihistamine before surgery.
- C. Notify the surgeon about the client's allergy to bananas.
- D. Prepare to administer an epinephrine injection during surgery
Correct Answer: A
Rationale: Banana allergy is associated with latex allergy. Replacing latex-containing devices prevents potential allergic reactions during surgery.
The most likely diagnosis in the patient described is
- A. persistent pulmonary hypertension
- B. transposition of the great arteries
- C. truncus arteriosus
- D. pulmonary atresia
Correct Answer: B
Rationale: Transposition of the great arteries often presents with cyanosis due to mixing of oxygenated and deoxygenated blood.
Childhood schizophrenia is suggested by:
- A. Disturbance in movement patterns
- B. Persistent thumb sucking
- C. Hallucinations
- D. Infantile autism
Correct Answer: C
Rationale: Hallucinations are a key feature of childhood schizophrenia. Movement disturbances and thumb sucking are nonspecific, and infantile autism is a separate condition.
An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?
- A. Teach a family member to administer eye drops
- B. Encourage deep breathing and coughing exercises
- C. Provide an eye shield to be worn while sleeping
- D. Obtain vital signs every 2 hours during hospitalization
Correct Answer: C
Rationale: An eye shield protects the surgical site from accidental trauma during sleep, which is critical for postoperative healing.
Pulmonary hypotension in a neonate associate with
- A. Diaphragmatic hernia
- B. Oxygen therapy
- C. Meconium aspiration
- D. Pneumothrax
Correct Answer: A
Rationale: Diaphragmatic hernia can lead to decreased lung expansion and pulmonary hypotension.