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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 post-TUNA is essential to identify potential complications such as urinary retention, infection, or bleeding, ensuring timely intervention.
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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.
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply.)
- A. Reorient to day and time frequently.
- B. Apply soft wrist restraints bilaterally.
- C. Administer a PRN dose of lorazepam.
- D. Turn the television on for distraction.
- E. Present a calm, supportive demeanor.
Correct Answer: A,C,E
Rationale: Reorienting to time, administering lorazepam, and maintaining a calm demeanor address anxiety and hallucinations, reducing distress without increasing stimulation or using restraints unnecessarily.
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: Eliminating whole milk and ice cream, which are high in fat, prevents gallbladder inflammation and gallstone formation, indicating successful learning about cholecystitis diet.
An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?
- A. Demonstrate the use of visual scanning during meals to the client and family.
- B. Explain that weight loss will be reversed after the acute phase of the stroke has ended.
- C. Suggest that the family bring foods from home that the client enjoys eating.
- D. Encourage the family to offer to feed the client when she does not eat her entire meal.
Correct Answer: A
Rationale: Teaching visual scanning compensates for visual perception deficits post-CVA, enabling the client to see all food on the tray, addressing the root cause of poor intake and improving nutrition.
To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)
- A. Teach the client breathing exercises.
- B. Establish a regular bladder routine.
- C. Perform chest physiotherapy.
- D. Encourage use of incentive spirometer.
- E. Initiate passive range of motion exercises.
Correct Answer: A,C,D,E
Rationale: Breathing exercises, chest physiotherapy, incentive spirometer use, and passive range of motion exercises directly address respiratory function and mobility, reducing the risk of pulmonary complications in ALS by improving lung expansion, mobilizing secretions, and maintaining joint mobility.