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A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
- A. Use incentive spirometer.
- B. Monitor urinary stream for decrease in output.
- C. Report when hematuria becomes pink tinged.
- D. Restrict physical activities.
Correct Answer: B
Rationale: Monitoring urinary stream for decreased output is critical post-TUNA to detect complications like urinary retention or infection, ensuring kidney function and procedure effectiveness.
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An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
- A. Clear, dark amber-colored urine.
- B. Improved level of consciousness.
- C. Prothrombin time within normal limits.
- D. Decreased abdominal girth.
Correct Answer: D
Rationale: Decreased abdominal girth indicates reduced ascites, a direct result of low sodium diet and albumin infusions, which reduce fluid retention and increase oncotic pressure.
A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. The client reports his feet feel uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement?
- A. Use a bed cradle to hold the covers off feet.
- B. Provide a warming pad (Aqua-pad or K-pad) to feet.
- C. Place warm blankets next to the client's feet.
- D. Medicate the client with a prescribed sedative.
Correct Answer: B
Rationale: A warming pad improves blood flow to the feet, addressing coolness due to diabetic neuropathy and poor circulation, while minimizing risks like burns in a client with reduced sensation.
While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?
- A. Calculate gestation from last menstrual cycle.
- B. Continue with surgery as scheduled.
- C. Perform a bedside pregnancy test.
- D. Notify the surgical team to cancel the surgery.
Correct Answer: C
Rationale: Performing a bedside pregnancy test immediately confirms or rules out pregnancy, ensuring safe surgical planning, as abdominal surgery poses risks to a fetus.
A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing food intake, the nurse should include which type of fluid limitation?
- A. Overall fluid intake.
- B. Tea and hot chocolate.
- C. Low-sodium soups.
- D. Citrus fruit juices.
Correct Answer: B
Rationale: Limiting tea and hot chocolate reduces oxalate intake, which can contribute to calcium oxalate stone formation, a common type of urinary tract calculi.
After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?
- A. Whole milk and daily servings of ice cream.
- B. Citrus fruit and melon with a salt substitute.
- C. Pasta with herbal butter and no meat sauce.
- D. Canned vegetables with additional table salt.
Correct Answer: A
Rationale: Avoiding high-fat foods like whole milk and ice cream prevents exacerbation of cholecystitis, demonstrating effective understanding of dietary restrictions.