Nokea
A client with benign prostatic hyperplasia (BPH) is post-operative following transurethral resection of the prostate (TURP) and is now receiving continuous bladder irrigation. Upon assessment, the nurse notes that the output from the urinary catheter has stopped. Which nursing intervention is most appropriate?
- A. Reinsert a new catheter
- B. Increase the infusion rate of the irrigation
- C. Attempt to dislodge a clot
- D. Contact the health care provider (HCP)
Correct Answer: C
Rationale: Attempting to dislodge a clot is appropriate to restore flow, as catheter obstruction is common post-TURP.
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The nurse is teaching a client about the newly prescribed medication, sevelamer. Which statement, if made by the client, would indicate a correct understanding of the teaching?
- A. My blood pressure may increase while I take this medication.
- B. This medication will help lower my calcium level.
- C. I should take this medication with my meal.
- D. I may experience bad diarrhea with this medication.
Correct Answer: C
Rationale: Sevelamer is taken with meals to bind dietary phosphate, reducing serum phosphorus. It does not affect blood pressure (D), lower calcium (A), or typically cause diarrhea (B).
The nurse is teaching a class on acid-base imbalances. It would be correct for the nurse to identify which of the following would cause respiratory acidosis? Select all that apply.
- A. Aspirin overdose
- B. Pneumothorax
- C. Opioid overdose
- D. Anxiety
- E. Renal disease
Correct Answer: B,C
Rationale: Pneumothorax and opioid overdose impair ventilation, causing CO2 retention and respiratory acidosis.
Intravenous therapies often consist of electrolyte replacement therapies. Select the electrolyte that is accurately paired with one of its functions.
- A. Sodium: The control and management of circulating blood volume.
- B. Bicarbonate: The regulation of extracellular fluid.
- C. Chloride: The regulation of plasma protein.
- D. Calcium: The metabolism of fats, carbohydrates, and proteins.
Correct Answer: A
Rationale: Sodium regulates circulating blood volume by maintaining osmotic balance.
Which of the following signs and symptoms may lead the nurse to suspect hypovolemia? Select all that apply.
- A. Decreased skin turgor
- B. Increased urine output
- C. Dry mucous membranes
- D. Weight gain
- E. Low blood pressure
Correct Answer: A,C,E
Rationale: Hypovolemia causes decreased skin turgor, dry mucous membranes, and low blood pressure due to reduced fluid volume.
The nurse is preparing a client for a renal ultrasound. Which of the following statements accurately describes the purpose of this procedure?
- A. It measures the concentration of potassium and sodium in the blood.
- B. It evaluates the function of the kidneys in producing red blood cells.
- C. It evaluates the size, shape, and location of the kidneys, as well as blood flow to the kidneys.
- D. It detects abnormal levels of urea in the bloodstream.
Correct Answer: C
Rationale: Renal ultrasound assesses kidney size, shape, location, and blood flow.