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A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
- A. Output of dark amber urine
- B. Output of clear, light pink urine
- C. Output of bright red urine
- D. Output of burgundy colored urine
Correct Answer: D
Rationale: The correct answer is D: Output of burgundy colored urine. This indicates possible hemorrhage, a serious complication post-TURP. Dark amber urine (A) may suggest dehydration. Clear, light pink urine (B) is expected due to bladder irrigation post-TURP. Bright red urine (C) is common initially but should decrease over time. Burgundy colored urine (D) indicates active bleeding and requires immediate intervention.
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A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
- A. Fresh flowers and potted plants in the room
- B. Use of public transportation
- C. Group activities
- D. Unrestricted visitors
Correct Answer: A
Rationale: The correct answer is A: Fresh flowers and potted plants in the room. Neutropenic clients are at high risk for infections due to low white blood cell count. Fresh flowers and plants can harbor bacteria and fungi that can potentially cause infections. Therefore, restricting fresh flowers and plants helps minimize the risk of infection. Choices B, C, and D are incorrect because they do not directly relate to the risk of infection in neutropenic clients. Using public transportation, engaging in group activities, or having visitors are generally safe as long as proper infection control measures are followed.
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?
- A. Cyanosis
- B. Agitation
- C. Hypotension
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Agitation. During an asthma attack, hypoxemia can lead to decreased oxygen supply to the brain, causing agitation due to hypoxia. Cyanosis (A) is a bluish discoloration of the skin and mucous membranes, indicating severe hypoxemia. Hypotension (C) is not typically associated with hypoxemia in asthma. Dizziness (D) is more commonly seen in conditions like hyperventilation rather than hypoxemia. In summary, agitation is the most likely manifestation of hypoxemia during an asthma attack due to decreased oxygen supply to the brain.
A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis?
- A. Vertigo
- B. Fatigue
- C. Excessive thirst
- D. Frequent urination
Correct Answer: A
Rationale: The correct answer is A: Vertigo. Essential hypertension can cause vertigo due to increased pressure in the blood vessels supplying the inner ear. Vertigo is a common symptom of hypertension. Fatigue (B) is a non-specific symptom seen in many conditions. Excessive thirst (C) and frequent urination (D) are more indicative of diabetes mellitus rather than essential hypertension.
A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider?
- A. White coating in the mouth
- B. Increased heart rate
- C. Insomnia
- D. Shortness of breath
Correct Answer: A
Rationale: The correct answer is A: White coating in the mouth. This adverse effect can indicate oral thrush, a fungal infection common with inhaled corticosteroids like fluticasone. The nurse should instruct the client to report this to the provider promptly for appropriate treatment. Increased heart rate (B) and insomnia (C) are common side effects of the medication but not usually serious enough to report immediately. Shortness of breath (D) is a symptom of poorly controlled asthma and should be addressed promptly but not considered an adverse effect of the medication in this context.
A nurse is assessing a client before a packed RBC transfusion. What data is most important to obtain?
- A. Blood pressure
- B. Temperature
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: B
Rationale: The correct answer is B: Temperature. Before a packed RBC transfusion, it is crucial to assess the client's temperature as hyperthermia can indicate a possible transfusion reaction. Monitoring temperature helps in early detection and intervention. Blood pressure (A) is important but not the most crucial in this context. Respiratory rate (C) and oxygen saturation (D) are relevant but may not indicate an immediate issue with the transfusion. Other choices are not provided.