Nokea
A client undergoes transurethral resection of the prostate (TURP). Which solution should the nurse have available postoperatively for continuous bladder irrigation (CBI)?
- A. Sterile water
- B. Sterile normal saline
- C. Sterile Dakin's solution
- D. Sterile water with 5% dextrose
Correct Answer: B
Rationale: Continuous bladder irrigation is done after TURP using sterile normal saline, which is isotonic. Sterile water is not used because the solution could be absorbed systemically, precipitating hemolysis and possibly kidney failure. Dakin's solution contains hypochlorite and is used only for wound irrigation in selected circumstances. Solutions containing dextrose are not introduced into the bladder.
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The nurse monitors a patient with acute pancreatitis. Which assessment finding indicates that paralytic ileus has developed?
- A. Inability to pass flatus
- B. Loss of anal sphincter control
- C. Severe, constant pain with rapid onset
- D. Firm, nontender mass palpable at the lower right costal margin
Correct Answer: A
Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. Option 4 is the description of the physical finding of liver enlargement.
The nurse is caring for an obese client on a weight loss program. Which method should the nurse use to most accurately assess the program's effectiveness?
- A. Monitor the client's weight.
- B. Monitor the client's intake and output.
- C. Calculate the client's daily caloric intake.
- D. Frequently check the client's serum protein levels.
Correct Answer: A
Rationale: The most accurate measurement of weight loss is weighing of the client. This should be done at the same time of the day, in the same clothes, and using the same scale. Options 2, 3, and 4 measure nutrition and hydration status but are not associated with effectiveness of the weight loss program.
A client is scheduled for computed tomography (CT) of the kidneys to rule out renal disease. Which should the nurse assess the client for before the procedure to best assure the client's safety?
- A. Allergies
- B. Familial renal disease
- C. Frequent antibiotic use
- D. Long-term diuretic therapy
Correct Answer: A
Rationale: The client undergoing any type of diagnostic testing involving possible dye administration should be questioned about allergies, specifically an allergy to shellfish or iodine. This is essential to identify the risk for potential allergic reaction to contrast dye, which may be used.
A client is diagnosed with cholecystitis. The nurse reviews the client's medical record, expecting to note documentation of which manifestations of this disorder? Select all that apply.
- A. Dyspepsia
- B. Dark stools
- C. Light-colored and clear urine
- D. Feelings of abdominal fullness
- E. Rebound tenderness in the abdomen
- F. Upper abdominal pain that radiates to the right shoulder
Correct Answer: A,D,E,F
Rationale: Cholecystitis is an inflammation of the gallbladder. Manifestations include dyspepsia; feelings of abdominal fullness; rebound tenderness (Blumberg's sign); upper abdominal pain or discomfort that can radiate to the right shoulder; pain triggered by a high-fat meal; clay-colored stools, dark urine, and possible steatorrhea; anorexia, nausea, and vomiting; eructation; flatulence; fever; and jaundice.
The nurse is developing a plan of care for a client who suffered a pelvic fracture following a motor vehicle crash (MVC). Which interventions should be included in the nursing care plan to prevent skin breakdown? Select all that apply.
- A. Minimize the force and friction applied to the skin.
- B. Massage vigorously over bony prominences twice daily.
- C. Perform a systematic skin inspection at least once a day.
- D. Cleanse the skin at the time of soiling and at routine intervals.
- E. Use pillows to keep the knees and other bony prominences from direct contact with one another.
- F. Use hot water and a mild cleansing agent that minimizes irritation and dryness of the skin when bathing the client.
Correct Answer: A,C,D,E
Rationale: The client in this question is at high risk for pressure injury. Interventions for prevention of pressure injuries include minimizing the force and friction applied to the skin; performing a systematic skin inspection at least once a day, giving particular attention to the bony prominences; cleansing the skin at the time of soiling and at routine intervals; avoiding the use of hot water; and using a mild cleansing agent that minimizes irritation and dryness of the skin. Pillows should be used to keep the knees and other bony prominences from direct contact with one another, because skin contact can promote breakdown. Massaging over bony prominences (especially vigorous) can be harmful to at-risk skin surfaces.