Nokea
A nurse is caring for a client who is postoperative following a TURP. Which of the following findings should the nurse report to the provider?
- A. The client reports a frequent urge to urinate.
- B. The client's urine is pink-tinged.
- C. The client's bladder irrigation fluid is clear.
- D. The client's urine output contains large clots.
Correct Answer: D
Rationale: Large clots in urine suggest hemorrhage, requiring immediate reporting. Urge to urinate, pink-tinged urine, and clear irrigation fluid are expected post-TURP.
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A nurse is caring for a client who is receiving IV gentamicin. Which of the following actions should the nurse take?
- A. Monitor the client's hearing.
- B. Administer the medication over 15 min.
- C. Check the client's blood glucose levels.
- D. Instruct the client to increase fluid intake.
Correct Answer: A
Rationale: Gentamicin risks ototoxicity, so hearing monitoring is critical. It's infused slowly, glucose isn't affected, and fluid intake depends on condition.
The nurse is reviewing the client's medical record.
Procedures
Planned endoscopy at 1300.
The nurse is reviewing the client's medical record. Procedures Planned endoscopy at 1300. The nurse is assisting with the care of a client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.
- A. Witness the client signing a consent for transfusion.
- B. Obtain a large bore IV catheter.
- C. Ensure two nurses confirm the information on the blood label.
- D. Ensure the transfusion tubing is flushed with dextrose 5% in water.
- E. Explain to the client that transfusion reactions are not serious.
Correct Answer: A,B,C
Rationale: Consent ensures informed agreement, a large-bore catheter prevents clotting, and dual verification reduces errors. Dextrose isn't used for flushing, and minimizing reaction severity is inaccurate.
A nurse is caring for a client who is postoperative following a total knee arthroplasty. Which of the following actions should the nurse take?
- A. Encourage the client to flex the knee every 2 hr.
- B. Apply a continuous passive motion machine as prescribed.
- C. Instruct the client to keep the leg in a dependent position.
- D. Administer a diuretic to reduce swelling.
Correct Answer: B
Rationale: A CPM machine promotes mobility and prevents stiffness as prescribed. Flexion timing varies, dependent positioning increases swelling, and diuretics aren't routine.
A nurse is caring for a client who is postoperative following a craniotomy. Which of the following actions should the nurse take?
- A. Position the client flat in bed.
- B. Monitor the client's neurological status every 2 hr.
- C. Encourage the client to cough vigorously.
- D. Administer a stool softener as needed.
Correct Answer: B
Rationale: Frequent neurological checks detect complications like increased intracranial pressure early. Flat positioning risks pressure, vigorous coughing is avoided, and stool softeners prevent straining.
A nurse is caring for a client who has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?
- A. Sodium
- B. Calcium
- C. Potassium
- D. Magnesium
Correct Answer: C
Rationale: Furosemide can cause hypokalemia, so potassium levels must be monitored. Sodium, calcium, or magnesium aren't primarily affected.