Nokea
A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?
- A. Urine output of 30 mL/hr
- B. Pink-tinged urine
- C. Small blood clots in the urine
- D. Blood pressure of 114/78 mm Hg
Correct Answer: C
Rationale: The presence of small blood clots in the urine is an expected finding after a TURP due to the surgical manipulation of the prostate bed and the bladder. However, larger clots can indicate excessive bleeding and should be reported promptly. Urine output of 30 mL/hr is within the expected range for post-TURP clients, indicating adequate kidney perfusion. Pink-tinged urine is also normal after a TURP due to minor bleeding from the surgical site. A blood pressure of 114/78 mm Hg is within normal limits and does not require immediate reporting.
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What is the correct method to teach a patient about self-administration of insulin?
- A. Inject into the upper arm
- B. Rotate injection sites
- C. Use a 45-degree angle for injection
- D. Use a 90-degree angle for injection
Correct Answer: D
Rationale: The correct method to teach a patient about self-administration of insulin is to use a 90-degree angle for injection. This angle ensures proper subcutaneous administration of insulin, which is essential for effective absorption. Injecting into the upper arm (Choice A) is not recommended for insulin administration. While rotating injection sites (Choice B) is important to prevent lipodystrophy, the angle of injection is crucial for proper insulin delivery. Using a 45-degree angle (Choice C) is more suitable for intramuscular injections, not for subcutaneous insulin injections.
A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?
- A. Encourage the client to increase fluid intake.
- B. Suction the client every 2 hours.
- C. Perform chest physiotherapy every 8 hours.
- D. Administer oxygen via nasal cannula.
Correct Answer: A
Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.
What is the appropriate action for a patient experiencing chest pain?
- A. Administer aspirin
- B. Reposition the patient
- C. Check oxygen saturation
- D. Prepare for surgery
Correct Answer: A
Rationale: The correct action for a patient experiencing chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation in patients with chest pain, as it has antiplatelet effects. Repositioning the patient may not address the underlying cause of the chest pain. Checking oxygen saturation is important but not the initial priority in this scenario. Surgery is not typically the first-line treatment for chest pain without further assessment and diagnostic procedures.
What is the priority nursing intervention for a patient with hyperkalemia?
- A. Administer calcium gluconate
- B. Administer insulin
- C. Administer sodium bicarbonate
- D. Administer a diuretic
Correct Answer: A
Rationale: The correct answer is to administer calcium gluconate. In hyperkalemia, the priority is to protect the heart from potential complications like arrhythmias. Calcium gluconate is the first-line treatment as it stabilizes the cardiac cell membrane. Insulin (Choice B) and sodium bicarbonate (Choice C) can be used in conjunction with other treatments to shift potassium into cells, but calcium gluconate is the priority. Administering a diuretic (Choice D) is not the primary intervention for hyperkalemia and can even worsen the condition by reducing potassium excretion.
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Serum potassium
- B. Platelets
- C. aPTT
- D. INR
Correct Answer: C
Rationale: The correct answer is C: aPTT. Monitoring the activated partial thromboplastin time (aPTT) is crucial when a client is receiving heparin therapy. The aPTT reflects the clotting time and helps assess the effectiveness of heparin in preventing clot formation. Keeping the aPTT within the therapeutic range ensures that the medication is working optimally. Choices A, B, and D are incorrect because serum potassium, platelets, and INR are not direct indicators of heparin's effectiveness or therapeutic range.