Nokea
A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP?
- A. To control bleeding in the bladder.
- B. To instill antibiotics into the bladder.
- C. To keep the catheter free from clot obstruction.
- D. To prevent bladder distention.
Correct Answer: C
Rationale: Continuous irrigation prevents clot formation and obstruction in the catheter, ensuring proper drainage post-TURP.
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A therapeutic milieu is:
- A. A safe environment of care that is conducive to the prevention of medical errors.
- B. A client care area that provides personal privacy and the confidentiality of medical information.
- C. A European method of design and color to promote health and wellness.
- D. The provision of a therapeutic environment of consistency to promote health.
Correct Answer: D
Rationale: A therapeutic milieu is a structured environment designed to promote healing and recovery through consistency, safety, and therapeutic interactions.
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse should assess the client for which of the following signs of diabetic ketoacidosis (DKA)? Select all that apply.
- A. Fruity breath odor.
- B. Kussmaul respirations.
- C. Bradycardia.
- D. Polyuria.
- E. Hypotension.
Correct Answer: A, B, D, E
Rationale: DKA presents with fruity breath (due to acetone), Kussmaul respirations (compensatory hyperventilation), polyuria (osmotic diuresis), and hypotension (dehydration). Bradycardia is not typical.
The nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the following laboratory values should the nurse monitor?
- A. Activated partial thromboplastin time (aPTT).
- B. Prothrombin time (PT).
- C. International normalized ratio (INR).
- D. D-dimer.
Correct Answer: A, D
Rationale: aPTT monitors heparin therapy, and D-dimer indicates clot presence in DVT.
A client with asthma has been prescribed beclomethasone (Beclovent) via metered-dose inhaler. To determine if the client has been rinsing the mouth after each use of the inhaler, the nurse should inspect the client's mouth for:
- A. Gingival hyperplasia.
- B. Oral candidiasis.
- C. Ulceration.
- D. Dental caries.
Correct Answer: B
Rationale: Beclomethasone, an inhaled corticosteroid, can cause oral candidiasis (thrush) if the mouth is not rinsed after use, as residual medication promotes fungal growth.
A 36-month-old child weighing 44 lb is to receive ceftriaxone (Rocephin) 2 g I.V. every 12 hours. The recommended dose of Rocephin is 50 to 75 mg/kg/day in divided doses. The nurse should:
- A. Administer the medication as ordered.
- B. Administer half the ordered dose.
- C. Call the laboratory to check the therapeutic serum level of Rocephin.
- D. Withhold administering the Rocephin and notify the child's physician.
Correct Answer: D
Rationale: 44 lb = 20 kg. Recommended dose: 50-75 mg/kg/day = 1000-1500 mg/day. 2 g (2000 mg) every 12 hours = 4000 mg/day, exceeding the safe dose, so the nurse should notify the physician.