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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 caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
- A. Atropine
- B. Epinephrine
- C. Magnesium
- D. Sodium bicarbonate
Correct Answer: A
Rationale: Rationale: Atropine is the correct answer because it is the first-line medication for symptomatic bradycardia. It works by blocking the parasympathetic nervous system, increasing heart rate. Epinephrine is used for cardiac arrest, not bradycardia. Magnesium is for torsades de pointes, not bradycardia. Sodium bicarbonate is for metabolic acidosis, not bradycardia.
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
- A. Thyroid hormones
- B. Antihypertensives
- C. Steroids
- D. Insulin
Correct Answer: C
Rationale: The correct answer is C: Steroids. Steroids, specifically glucocorticoids, are known to increase the risk of osteoporosis by decreasing bone formation and increasing bone resorption. Long-term use of steroids can lead to bone loss, making individuals more susceptible to fractures. Thyroid hormones (A) do not directly cause osteoporosis. Antihypertensives (B) and insulin (D) are not associated with increased risk of osteoporosis.
A nurse works with an AP assigned to bathe a client with herpes zoster. The AP asks if it is contagious. What should the nurse say?
- A. Herpes zoster is not contagious to people who have had chickenpox.
- B. Herpes zoster spreads through the air.
- C. Herpes zoster is highly contagious to everyone.
- D. Herpes zoster only spreads through blood contact.
Correct Answer: A
Rationale: The correct answer is A. Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus, which also causes chickenpox. Individuals who have had chickenpox in the past are not at risk of getting shingles from someone with herpes zoster. The virus is not transmitted through the air (choice B) or through blood contact only (choice D). It is not highly contagious to everyone (choice C). By explaining to the AP that herpes zoster is not contagious to individuals who have had chickenpox, the nurse provides accurate information and helps alleviate concerns about the spread of the virus.
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. Serum albumin level
- B. WBC count
- C. Serum potassium level
- D. BUN
Correct Answer: B
Rationale: The correct answer is B: WBC count. An elevation in WBC count indicates an immune response to infection, as white blood cells increase to fight off pathogens. In the context of a pressure ulcer, an elevated WBC count suggests the presence of infection due to the body's response to foreign organisms. Other choices are not directly related to infection in this scenario. Serum albumin level (A) reflects nutritional status, serum potassium level (C) indicates electrolyte balance, and BUN (D) reflects kidney function. Hence, they are not specific indicators of infection in a client with a pressure ulcer.
A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?
- A. Abnormally prominent U wave
- B. Tachycardia
- C. Flattened P wave
- D. Prolonged PR interval
Correct Answer: A
Rationale: The correct answer is A: Abnormally prominent U wave. In hypokalemia, low potassium levels can lead to U wave prominence on an EKG. The U wave becomes more visible and prominent due to delayed repolarization of the Purkinje fibers. This is a classic EKG finding in hypokalemia. Tachycardia (choice B) is a non-specific finding and can be caused by various conditions. Flattened P wave (choice C) is seen in hyperkalemia, not hypokalemia. Prolonged PR interval (choice D) is more indicative of first-degree heart block or other conduction abnormalities, not specifically hypokalemia.