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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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The nurse is monitoring a client in the telemetry unit who has recently been admitted with the diagnosis of chest pain and notes this heart rate pattern on the monitoring strip. What is the initial action to be taken by the nurse?
- A. Notify the primary health care provider.
- B. Initiate cardiopulmonary resuscitation (CPR).
- C. Continue to monitor the client and the heart rate patterns.
- D. Administer oxygen with a face mask at 8 to 10 L per minute.
Correct Answer: B
Rationale: The monitor is showing ventricular fibrillation, a life-threatening dysrhythmia that requires CPR and defibrillation to maintain life. Although the primary health care provider must be notified, CPR is the initial action. Oxygen is necessary, but again the initiation of CPR is the priority because it will provide more than just oxygen to the client. Monitoring the client is necessary, but not as an initial action; emergency resuscitative treatment must be provided to the client immediately.
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.
The nurse admitting a client diagnosed with myocardial infarction (MI) to the coronary care unit (CCU) should plan care by implementing which intervention?
- A. Beginning thrombolytic therapy
- B. Placing the client on continuous cardiac monitoring
- C. Infusing intravenous (IV) fluid at a rate of 150 mL per hour
- D. Administering oxygen at a rate of 6 L per minute by nasal cannula
Correct Answer: B
Rationale: Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring. Thrombolytic therapy may or may not be prescribed by the primary health care provider. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event. The nurse should ensure that there is an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep-vein-open rate to prevent fluid overload and heart failure. Oxygen should be administered at a rate of 2 to 4 L per minute unless otherwise prescribed.
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.
An adult client arrives in the emergency department with burns to both entire legs and the perineal area. Using the rule of nines, the nurse should determine that approximately what percentage of the client's body surface has been burned? Fill in the blank.
Correct Answer: 37%
Rationale: The most rapid method used to calculate the size of a burn injury in adult clients whose weights are in normal proportion to their heights is the rule of nines. This method divides the body into areas that are multiples of 9%, except for the perineum. Each entire leg is 18%, each arm is 9%, and the head is 9%. The trunk is 36%, and the perineal area is 1%. Both legs and perineal area equal 37%.