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A client with a posterior wall bladder injury has had surgical repair and placement of a suprapubic catheter. What intervention should the nurse plan to implement to prevent complications associated with the use of this catheter?
- A. Monitor urine output every shift.
- B. Measure specific gravity once a shift.
- C. Encourage a high intake of oral fluids.
- D. Avoid kinking of the catheter tubing.
Correct Answer: D
Rationale: A complication after surgical repair of the bladder is disruption of sutures caused by tension on them from urine buildup. The nurse prevents this from happening by ensuring that the catheter is able to drain freely. This involves basic catheter care, including keeping the tubing free from kinks, keeping the tubing below the level of the bladder, and monitoring the flow of urine frequently. Monitoring urine output every shift is insufficient to detect decreased flow from catheter kinking. Measurement of urine specific gravity and a high oral fluid intake do not prevent complications of bladder surgery.
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A client is scheduled for hydrotherapy for a burn dressing change. Which action should the nurse take to ensure that the client is comfortable during the procedure?
- A. Ensure that the client is appropriately dressed.
- B. Administer an opioid analgesic 30 to 60 minutes before therapy.
- C. Schedule the therapy at a time when the client generally takes a nap.
- D. Assign an unlicensed assistive personnel (UAP) to stay with the client during the procedure.
Correct Answer: B
Rationale: The client should receive pain medication approximately 30 to 60 minutes before a burn dressing change. This will help the client tolerate an otherwise painful procedure. None of the remaining options addresses the issue of pain effectively.
A coronary care unit (CCU) nurse is caring for a client admitted with acute myocardial infarction (MI). The nurse should monitor the client for which most common complication of MI?
- A. Heart failure
- B. Cardiogenic shock
- C. Cardiac dysrhythmias
- D. Recurrent myocardial infarction
Correct Answer: C
Rationale: Dysrhythmias are the most common complication and cause of death after an MI. Heart failure, cardiogenic shock, and recurrent MI are also complications but occur less frequently.
The nurse reviews the client's vital signs in the client's chart. Based on these data findings, what is the client's pulse pressure? Fill in the blank.
Correct Answer: 74 mm Hg
Rationale: The difference between the systolic and diastolic blood pressure is the pulse pressure. Therefore, if the client has a blood pressure of 146/72 mm Hg, then the pulse pressure is 74.
A client is receiving cisplatin. On assessment of the client, which findings indicate that the client is experiencing an adverse effect of the medication?
- A. Tinnitus
- B. Increased appetite
- C. Excessive urination
- D. Yellow halos in front of the eyes
Correct Answer: A
Rationale: Cisplatin is an antineoplastic medication. An adverse effect related to the administration of cisplatin is ototoxicity with hearing loss. The nurse should assess for this adverse reaction when administering this medication. Options 2, 3, and 4 are not adverse effects of this medication.
The nurse, caring for a client in the active stage of labor, is monitoring the fetal status and notes that the monitor strip shows a late deceleration. Based on this observation, which action should the nurse plan to take immediately?
- A. Document the findings.
- B. Prepare for immediate birth.
- C. Increase the rate of an oxytocin infusion.
- D. Administer oxygen to the client via face mask.
Correct Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency as the result of decreased blood flow and oxygen transfer to the fetus through the intervillous space during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. Although the finding needs to be documented, documentation is not the priority action in this situation. Late decelerations are considered an ominous sign but do not necessarily require immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because the medication stimulates contractions and leads to increased uteroplacental insufficiency.