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A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first?
- A. Determine the patency of the tubing.
- B. Notify the provider.
- C. Administer a prescribed analgesic.
- D. Offer oral fluids.
Correct Answer: A
Rationale: Determining tubing patency is the first action to check for blockages, preventing complications like bladder distention.
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A nurse is reinforcing dietary instructions with a client who has chronic kidney disease. Which of the following information should the nurse include?
- A. Maintain a low carbohydrate diet.
- B. Eliminate ingestion of foods high in protein.
- C. Increase intake of sodium-containing food.
- D. Reduce intake of foods high in potassium.
Correct Answer: D
Rationale: Reducing foods high in potassium is crucial in CKD to prevent hyperkalemia due to impaired renal potassium excretion.
A nurse is collecting data from a client who has peripheral arterial disease (PAD). Which of the following findings should the nurse expect?
- A. Warm extremities.
- B. Darkened skin color near extremities.
- C. Intermittent claudication.
- D. Edema.
Correct Answer: C
Rationale: Intermittent claudication, pain or cramping in the legs during exercise that subsides with rest, is a hallmark symptom of PAD due to reduced blood flow.
A nurse is reinforcing teaching with a client who has recurrent urinary tract infections (UTIs) about prevention measures. Which of the following client statements indicates the need for further teaching?
- A. I should avoid taking bubble baths.
- B. I will need to empty my bladder after having sexual intercourse.
- C. I will need to wipe my perineal area from back to front after urination.
- D. I need to drink at least 8 full glasses of liquid each day.
Correct Answer: C
Rationale: Wiping from back to front can transfer bacteria to the urethra, increasing UTI risk, indicating a need for further teaching on proper hygiene.
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse determines that teaching has been effective when the client identifies which of the following manifestations of hypoglycemia? (Select all that apply)
- A. Polyuria.
- B. Sweating.
- C. Blurry vision.
- D. Tachycardia.
- E. Polydipsia.
Correct Answer: B,C,D
Rationale: Sweating, blurry vision, and tachycardia are manifestations of hypoglycemia due to adrenaline release and glucose deficiency affecting bodily functions.
A nurse is preparing to administer potassium chloride 30 mEq PO daily. The amount available is potassium chloride 20 mEq/15mL. How many mL should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. (Do not use a trailing zero))
Correct Answer: 22.6 mL
Rationale: 30 mEq ÷ (20 mEq/15 mL) = 22.56 mL, rounded to 22.6 mL.