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A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Which of the following actions should the nurse take?
- A. Monitor the client's urine output every 4 hr.
- B. Irrigate the catheter with sterile water every 2 hr.
- C. Check the catheter tubing for blood clots.
- D. Administer an antibiotic prophylactically.
Correct Answer: C
Rationale: Checking for clots ensures catheter patency, critical for irrigation. Output monitoring is secondary, manual irrigation isn't routine, and antibiotics depend on orders.
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A nurse is caring for a client who is postoperative following a hysterectomy. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate as tolerated.
- B. Instruct the client to avoid deep breathing exercises.
- C. Apply a warm compress to the incision site.
- D. Administer a sedative every 4 hr.
Correct Answer: A
Rationale: Ambulation prevents complications like thromboembolism. Deep breathing aids recovery, warm compresses risk infection, and sedatives aren't routine.
A nurse is reinforcing teaching with a client who has a new prescription for warfarin. Which of the following statements should the nurse include?
- A. You should avoid eating spinach and kale.
- B. You can take ibuprofen for a headache.
- C. You should take the medication at bedtime.
- D. You can continue to participate in contact sports.
Correct Answer: A
Rationale: Spinach and kale, high in vitamin K, can interfere with warfarin's anticoagulant effect. Ibuprofen, variable dosing times, or contact sports increase bleeding risks.
A nurse is reinforcing teaching with a client who has gout and a new prescription for allopurinol. Which of the following statements should the nurse include?
- A. You should limit your intake of vitamin C.
- B. You might experience a skin rash while taking this medication.
- C. You can take this medication with an antacid to reduce stomach upset.
- D. You should avoid drinking coffee while taking this medication.
Correct Answer: B
Rationale: Allopurinol can cause rashes, a potential sign of serious reactions. Vitamin C, antacids, or coffee don't significantly interact with allopurinol.
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.
A nurse is caring for a client who is receiving IV fluids with potassium chloride. Which of the following findings should the nurse report to the provider?
- A. The client reports mild discomfort at the IV site.
- B. The client's heart rate is irregular.
- C. The client's urine output is 50 mL/hr.
- D. The client's blood pressure is 118/76 mm Hg.
Correct Answer: B
Rationale: An irregular heart rate suggests hyperkalemia or arrhythmia, requiring reporting. Mild discomfort, normal urine output, and stable BP are less concerning.