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A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
- A. Hemorrhage
- B. Infection
- C. Urinary retention
- D. Pain
Correct Answer: A
Rationale: The correct answer is A: Hemorrhage. Postoperative hemorrhage is a critical complication following a transurethral resection of the prostate due to the rich blood supply in the area. It can lead to hypovolemic shock and requires immediate intervention to prevent further complications. Monitoring for signs of bleeding such as increased heart rate, decreased blood pressure, and decreased urine output is crucial.
B: Infection is an important complication to monitor for but is not as immediately life-threatening as hemorrhage.
C: Urinary retention can occur postoperatively but is not as urgent as hemorrhage.
D: Pain management is important for the client's comfort, but it is not the priority in this situation.
In summary, monitoring for hemorrhage is crucial as it is the most life-threatening complication that requires immediate attention compared to the other options.
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A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?
- A. Akathisia
- B. Tardive dyskinesia
- C. Dystonia
Correct Answer: B
Rationale: The correct answer is B: Tardive dyskinesia. Tardive dyskinesia is a common adverse effect of long-term antipsychotic medication use, such as chlorpromazine. It is characterized by involuntary movements of the tongue and face. This condition is often irreversible and can be distressing for the client. Akathisia (choice A) is a different extrapyramidal side effect characterized by restlessness and the urge to move constantly. Dystonia (choice C) is another extrapyramidal side effect that presents as sustained muscle contractions causing abnormal postures. In this case, the symptoms described in the question are more indicative of tardive dyskinesia due to the specific type of involuntary movements observed in the client.
A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply)
- A. The medication will reduce inflammation.
- B. The medication will decrease coughing episodes.
- C. The medication will prevent wheezing.
- D. The medication will open the airway.
- E. The medication will stimulate the flow of mucus.
Correct Answer: C,D
Rationale: Correct Answer: C,D
Rationale:
C: The medication will prevent wheezing. Albuterol is a bronchodilator that works by relaxing the muscles in the airways, preventing and relieving wheezing.
D: The medication will open the airway. Albuterol acts by opening the airways, making it easier for the client to breathe.
Summary:
A: The medication will reduce inflammation. Albuterol does not directly reduce inflammation; it primarily works as a bronchodilator.
B: The medication will decrease coughing episodes. While albuterol may indirectly reduce coughing by improving breathing, its primary action is not to decrease coughing.
E: The medication will stimulate the flow of mucus. Albuterol does not stimulate mucus flow; it primarily works to open the airways and relieve bronchospasm.
A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.8
Rationale: To calculate the mL of enoxaparin needed, divide the desired dose (30 mg) by the concentration (40 mg/mL): 30 mg / 40 mg/mL = 0.75 mL. Since the answer should be rounded to the nearest tenth, 0.75 rounds up to 0.8 mL. Therefore, the correct answer is 0.8 mL.
Choice A (0.5 mL) is incorrect as it is not the result of the calculation. Choices B, C, D, E, F, and G are also incorrect as they do not match the correct answer derived from the calculation.
A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?
- A. Flu-like symptoms and night sweats
- B. Fungal and bacterial infections
- C. Pneumocystis lung infection
- D. Kaposi’s sarcoma
Correct Answer: A
Rationale: The correct answer is A: Flu-like symptoms and night sweats. Initial symptoms of HIV infection often present as flu-like symptoms such as fever, fatigue, sore throat, swollen lymph nodes, and night sweats. This is known as acute retroviral syndrome and occurs within the first few weeks after exposure to the virus. These symptoms are nonspecific and can easily be mistaken for other common illnesses. Fungal and bacterial infections (B), Pneumocystis lung infection (C), and Kaposi’s sarcoma (D) are not initial symptoms of HIV infection. Fungal and bacterial infections typically occur in later stages of HIV when the immune system is severely compromised. Pneumocystis lung infection and Kaposi’s sarcoma are opportunistic infections seen in advanced stages of HIV, usually when the CD4 count is significantly low.
A nurse is caring for a client who is postpartum and asks the nurse when her breast milk will 'come in.' Which of the following responses should the nurse make?
- A. Within 2 days.
- B. In 3 to 5 days.
- C. In about 10 days.
- D. In 6 to 8 days.
Correct Answer: B
Rationale: The correct answer is B: In 3 to 5 days. This is because breast milk typically comes in around 3 to 5 days after giving birth, as it takes time for hormonal changes to trigger milk production. Option A (Within 2 days) is too soon for most women to experience lactogenesis II. Option C (In about 10 days) and Option D (In 6 to 8 days) are both incorrect as they are outside the typical timeframe for milk production to start. It's important for the nurse to provide accurate information to the client to manage her expectations and provide proper support during this crucial time.