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A client who had transurethral resection of the prostate complains of dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had $200 \mathrm{~mL}$ of urine output in the last 8 hours with a $1,000 \mathrm{~mL}$ intake. Which of the following interventions is a priority for the nurse at this time?
- A. Apply a condom catheter
- B. Assess for bladder distention
- C. Obtain a urine specimen for culture
- D. Teach the client Kegel exercises
Correct Answer: B
Rationale: Low urine output and dribbling post-TURP suggest possible bladder distention, which requires immediate assessment to prevent complications. Other interventions may follow based on findings.
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The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left-sided deficits. The nurse plans care with the understanding that which action would be least helpful?
- A. Place bedside articles on the left side.
- B. Approach the client from the right side.
- C. Teach the client to scan the environment.
- D. Move the commode and chair to the left side.
Correct Answer: B
Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. Personal care items, belongings, a bedside chair, and a commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and caregivers as well.
The nurse is caring for a client with a venous leg ulcer. Which of the following interventions should be included in the plan of care?
- A. Apply compression bandages.
- B. Keep the leg in a dependent position.
- C. Clean the ulcer with alcohol-based solution.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Compression bandages promote venous return and healing in venous leg ulcers.
Which of the following baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)?
- A. Potassium level.
- B. Lee-White clotting time.
- C. Hemoglobin level, hematocrit, and platelet count.
- D. Blood glucose level.
Correct Answer: C
Rationale: These tests assess bleeding risk, critical before administering thrombolytics like alteplase, which can cause hemorrhage.
A client with a history of depression is prescribed bupropion (Wellbutrin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Seizures.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bupropion lowers the seizure threshold, and seizures are a serious side effect requiring immediate reporting.
A client with a history of tuberculosis is prescribed isoniazid (INH). The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Isoniazid can cause hepatotoxicity, requiring regular liver function monitoring.