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 causative organisms for endocarditis in pediatric patients are
- A. enterococci
- B. group B streptococci
- C. viridans-type streptococci
- D. Pseudomonas aeruginosa
Correct Answer: C
Rationale: Viridans streptococci are the most common cause of endocarditis in pediatric patients.
The differential diagnosis of the patient includes all of the following EXCEPT
- A. rheumatic fever
- B. SLE
- C. chronic atrial fibrillation
- D. postmeningococcal immune complexes
Correct Answer: C
Rationale: Chronic atrial fibrillation is unlikely in an 8-year-old with acute onset symptoms.
The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best evidence that the client is adhering to the prescribed diabetic regimen?
- A. Hemoglobin A1C of 6.2%
- B. Fasting blood glucose of 130 mg/dL
- C. Positive urine ketones
- D. Self-reported daily blood glucose monitoring
Correct Answer: A
Rationale: A hemoglobin A1C of 6.2% indicates good glycemic control, reflecting adherence to the diabetic regimen.
The healthcare provider prescribes epoetin alfa (Procrit) 8,200 units subcutaneously for a client with chronic kidney disease (CKD). The 2 ml multidose vial is labeled, 'Each 1 ml of solution contains 10,000 units of epoetin alfa.' How many ml should the nurse administer?
- A. 0.8
- B. 8
- D. 1
Correct Answer: A
Rationale: To calculate the dose, the nurse must divide the prescribed dose (8,200 units) by the concentration (10,000 units per ml). 8,200 ÷ 10,000 = 0.82 ml, rounded to 0.8 ml.
Gingival hyperplasia is an adverse effect of therapy with:
- A. Phenytoin
- B. Cyclophosphamide
- C. Frusemide
- D. Carbamazepine
Correct Answer: A
Rationale: Phenytoin, an anticonvulsant medication, is well-known for causing gingival hyperplasia as a side effect.