Nokea
A nurse is caring for a client who is receiving continuous bladder irrigation. Which of the following actions should the nurse take?
- A. Monitor the client's urine output hourly.
- B. Irrigate the catheter with sterile water every 4 hr.
- C. Check the irrigation fluid for blood.
- D. Encourage the client to increase oral fluid intake.
Correct Answer: C
Rationale: Checking irrigation fluid for blood ensures patency and detects bleeding. Hourly output is excessive, manual irrigation isn't routine, and oral intake depends on orders.
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A nurse is caring for a client who is postoperative following a cesarean birth. Which of the following actions should the nurse take?
- A. Encourage the client to ambulate within 24 hr.
- B. Instruct the client to avoid coughing.
- C. Apply a cold pack to the incision site.
- D. Administer a laxative every 2 hr.
Correct Answer: A
Rationale: Ambulation within 24 hours prevents thromboembolism and aids recovery. Coughing supports lung function, cold packs aren't standard, and laxatives aren't given that frequently.
A nurse is reinforcing teaching with a client who has a new prescription for citalopram. Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. You might have dry mouth while taking this medication.
- C. You need to avoid tyramine-rich foods.
- D. You can expect your mood to improve right away.
Correct Answer: B
Rationale: Citalopram can cause dry mouth, a side effect to anticipate. Timing is flexible, tyramine isn't a concern, and mood improvement takes weeks.
A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
- A. Weight loss
- B. Decreased blood pressure
- C. Decreased skin turgor
- D. Crackles heard in the lungs
Correct Answer: D
Rationale: Crackles in the lungs indicate pulmonary edema from fluid overload. Weight loss, low blood pressure, or poor skin turgor suggest dehydration, not overload.
A nurse is caring for a client who is postoperative following a hip replacement. Which of the following actions should the nurse take?
- A. Place an abduction pillow between the client's legs.
- B. Instruct the client to bend at the hip when sitting.
- C. Apply a warm compress to the surgical site.
- D. Encourage the client to cross their legs when seated.
Correct Answer: A
Rationale: An abduction pillow prevents dislocation by maintaining hip alignment. Bending, warm compresses, and leg crossing increase dislocation risk.
A nurse is caring for a client who is postoperative following a craniotomy. Which of the following findings should the nurse report to the provider?
- A. The client reports a headache.
- B. The client's pupils are unequal.
- C. The client's incision has minimal drainage.
- D. The client's blood pressure is 130/85 mm Hg.
Correct Answer: B
Rationale: Unequal pupils suggest increased intracranial pressure or neurological deterioration, requiring reporting. Headache, minimal drainage, and normal BP are less urgent.