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A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.)
- A. Contact the surgeon if the client reports a continual need to void.
- B. Use sterile technique when preparing the irrigation solution.
- C. Add the amount of bladder irrigation to the total output.
- D. Notify the surgeon if the urine is bright red or has large clots.
- E. Make sure the drainage tubing is patent and without obstruction.
Correct Answer: B,D,E
Rationale: Using sterile technique, notifying the surgeon for bright red urine or clots, and ensuring tubing patency are critical to prevent infection, manage bleeding, and maintain irrigation effectiveness.
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A nurse is collecting data from a client who has end-stage kidney disease and is waiting for transport to dialysis. Which of the following findings should the nurse expect?
- A. Diaphoresis.
- B. Hypotension.
- C. Peripheral edema.
- D. Facial flushing.
Correct Answer: C
Rationale: Peripheral edema is common in end-stage kidney disease due to the kidneys' inability to remove excess fluid.
A nurse is reinforcing discharge teaching with a client who has osteoarthritis. Which of the following statements by the client indicates an understanding of the teaching?
- A. Osteoarthritis is caused by inflammation that affects both joints and other body tissues.
- B. Osteoarthritis occurs due to the aging process and results in disintegration of cartilage in a joint.
- C. Osteoarthritis is due to loss of calcium in the bones, which can lead to increased risk for bone fractures.
- D. Osteoarthritis happens in several phases when deposits of crystals develop in joints and soft tissues.
Correct Answer: B
Rationale: Osteoarthritis is a degenerative joint disease caused by aging and cartilage disintegration, as correctly stated.
A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching?
- A. You should wear glasses instead of contacts while taking this medication.
- B. A yellow tint to the skin is an expected reaction to the medication.
- C. Lifelong treatment with this medication is necessary.
- D. The medication causes amenorrhea if taken along with an oral contraceptive.
Correct Answer: A
Rationale: Rifampin can cause discoloration of body fluids, including tears, which can stain contact lenses. Therefore, it is recommended to wear glasses instead of contacts while taking this medication.
A nurse is preparing to administer levothyroxine 275 mcg PO to a client. The amount available is levothyroxine 137 mcg/tablet. How many tablets should the nurse administer?
- A. 2 tablets
- B. 1 tablet
- C. 3 tablets
- D. 4 tablets
Correct Answer: A
Rationale: 275 mcg ÷ 137 mcg/tablet = 2.007 tablets, rounded to 2 tablets.
A nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?
- A. Place a sandbag to the lateral calf.
- B. Place a wedge pillow between the legs.
- C. Place a trochanter roll against the thigh.
- D. Place a footboard on the bed.
Correct Answer: B
Rationale: Placing a wedge pillow between the legs maintains hip abduction, preventing adduction and reducing the risk of dislocation after hip arthroplasty.