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A client with BPH has undergone a TURP. Which nursing interventions are parts of the client's post-operative care?
- A. Monitoring the client's vital signs
- B. Maintaining constant bladder irrigation
- C. Limiting fluid intake to 1000 mL per day
- D. Checking for post-operative bleeding
- E. Maintaining bed rest for 48 hours
Correct Answer: A, B, D
Rationale: Post-TURP care includes monitoring vital signs (A), constant bladder irrigation (B) to prevent clots, and checking for bleeding (D). Fluid intake is encouraged (C), and bed rest is typically 24 hours (E).
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A client with a history of chronic migraines is admitted with complaints of headache. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring blood pressure
- C. Providing a quiet environment
- D. Administering oxygen
Correct Answer: C
Rationale: A quiet environment reduces sensory stimuli, which can exacerbate migraines, making it a priority to promote comfort.
A client with a history of a hiatal hernia is being taught about dietary management. The nurse should encourage the client to:
- A. Eat large meals
- B. Avoid caffeine
- C. Lie down after meals
- D. Eat high-fat foods
Correct Answer: B
Rationale: Caffeine relaxes the lower esophageal sphincter, worsening hiatal hernia symptoms. Small meals, avoiding lying down post-meals, and low-fat foods are recommended.
The doctor has prescribed aspirin 325 mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
- A. Prevent headaches
- B. Boost coagulation
- C. Prevent cerebral anoxia
- D. Decrease platelet aggregation
Correct Answer: D
Rationale: Aspirin reduces platelet aggregation, preventing clot formation in transient ischemic attacks, reducing stroke risk. It does not prevent headaches, boost coagulation, or directly prevent anoxia.
A client with sickle cell disease is admitted in active labor. Which nursing intervention would be most helpful in preventing a sickling crisis?
- A. Obtaining blood pressures every two hours
- B. Administering pain medication every three hours as ordered
- C. Monitoring arterial blood gas results
- D. Administering IV fluids at ordered rate of 200 mL/hr
Correct Answer: D
Rationale: IV fluids at 200 mL/hr prevent dehydration, a trigger for sickling crises, by maintaining hydration and blood flow. BP monitoring (A), pain medication (B), and ABGs (C) are supportive but less directly preventive.
A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature:
- A. Increase cardiac output
- B. Indicate cardiac tamponade
- C. Decrease cardiac output
- D. Indicate graft rejection
Correct Answer: C
Rationale: Fever post-CABG increases metabolic demand, potentially decreasing cardiac output in a compromised heart, requiring immediate attention. Tamponade and rejection have other signs.