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A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make?
- A. Assess the patency of the Foley catheter
- B. Assess urine for excessive bleeding
- C. Assess urine for excessive bleeding
- D. Obtain a urine specimen for culture
Correct Answer: B
Rationale: Assessing for excessive bleeding post-cystoscopy with biopsy is critical due to the risk of hemorrhage. A Foley catheter may not be present, and culture is less urgent.
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A 13-year-old client is dying of cancer and struggling with the emotional aspects of this. When providing care for this client, the nurse should incorporate the developmental tasks for this age. According to Erikson's developmental model, the child normally is expected to be working on which of the following psychosocial issues?
- A. Identity vs. role confusion.
- B. Intimacy vs. isolation.
- C. Industry vs. inferiority.
- D. Autonomy vs. shame and doubt.
Correct Answer: A
Rationale: Adolescents (ages 12–18) focus on identity vs. role confusion, developing a sense of self and personal identity.
A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has $300 \mathrm{~mL}$ of solution left. The nurse should:
- A. Continue the infusion until the remaining 300mL is infused
- B. Change the filter on the tubing and continue with the infusion
- C. Notify the physician and obtain orders to alter the rate of the solution
- D. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution
Correct Answer: D
Rationale: TPN solutions should not hang for more than 24 hours due to infection risk. The nurse should discontinue the current bag, change the tubing, and hang a new bag. Continuing or altering the rate is unsafe.
The nurse is preparing to implement emergency care measures for the client who has just demonstrated signs and symptoms of a pulmonary embolism. Which primary health care provider prescription should the nurse implement first?
- A. Apply oxygen.
- B. Administer morphine sulfate.
- C. Start an intravenous (IV) line.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: The client needs oxygen immediately because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should also have an IV line for the administration of emergency medications such as morphine sulfate. An ECG is useful in determining the presence of possible right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first.
Select the types and stages of conflict that are accurately paired with their description. Select all that apply.
- A. Frustration: The phase of conflict that is characterized with personal agendas and obstruction
- B. Conceptualization: The phase of conflict that occurs when contending parties have developed a clear and objective understanding of the nature of the conflict and factors that have led to it
- C. Taking action: The phase of conflict that is characterized with individual responses to and feelings about the conflict
- D. Resolution: The type of conflict that can be resolved
- E. Avoidance-Avoidance: A stage of conflict that occurs when there are NO alternatives that are acceptable to the contending parties
- F. Approach- Approach Conflicts: The type of conflict that occurs when the people involved in the conflict want more than one alternatives or actions that could resolve the conflict.
- G. Approach-Avoidance Conflicts: The type of conflict that occurs when the people involved in the conflict believe that all of the alternatives are NEITHER completely satisfactory nor completely dissatisfactory.
Correct Answer: B,D,F,G
Rationale: Conceptualization is correctly described as understanding the conflict's nature. Resolution refers to conflicts that can be resolved. Approach-Approach (F) involves choosing between desirable alternatives, and Approach-Avoidance (G) involves alternatives with both positive and negative aspects. Frustration is not about personal agendas but emotional responses, Taking action involves implementing solutions, not just feelings, and Avoidance-Avoidance is a type, not a stage, of conflict.
A family has been notified that their son is brain dead, and the physician has discussed the possibility of donating organs. The nurse should collaborate with the physician to contact which referral source that is responsible for organ recovery in the United States?
- A. Organ and Tissue Procurement Organizations.
- B. American Transplant Association.
- C. American Hospice Foundation.
- D. American Association of Critical-Care Nurses.
Correct Answer: A
Rationale: Organ and Tissue Procurement Organizations are responsible for coordinating organ recovery in the United States, as they manage the donation process and ensure compliance with regulations.