Nokea
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications?
- A. Encourage the use of an incentive spirometer
- B. Administer oxygen therapy
- C. Provide early ambulation
- D. Monitor for chest pain
Correct Answer: A
Rationale: The correct answer is A: Encourage the use of an incentive spirometer. This intervention helps prevent pulmonary complications postoperatively by promoting deep breathing, improving lung expansion, and preventing atelectasis. Incentive spirometry helps the client maintain lung function and prevent respiratory complications such as pneumonia. Administering oxygen therapy (B) is important but not as effective in preventing complications as using an incentive spirometer. Early ambulation (C) is beneficial for circulation but does not directly prevent pulmonary complications. Monitoring for chest pain (D) is essential for assessing cardiac issues but does not specifically address pulmonary complications.
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A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide?
- A. Take the medication early in the day.
- B. Take the medication at bedtime.
- C. Take the medication with food.
- D. Take the medication only when blood pressure is high.
Correct Answer: A
Rationale: The correct answer is A: Take the medication early in the day. Hydrochlorothiazide is a diuretic that increases urine production, which can cause frequent urination. Taking it early helps prevent nighttime urination, promoting better sleep. Taking it with food may reduce gastrointestinal upset. Taking it only when blood pressure is high is incorrect, as it should be taken regularly to maintain consistent blood pressure control. Bedtime dosing may lead to nocturnal diuresis and disturb sleep. The other choices are irrelevant or incorrect in the context of hydrochlorothiazide administration.
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.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Chest pain
- B. Hypotension
- C. Generalized urticaria
- D. Fever
Correct Answer: C
Rationale: The correct answer is C: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. It is caused by histamine release in response to the foreign blood product. Chest pain (A) is more indicative of a possible cardiac issue. Hypotension (B) may suggest a hemolytic reaction due to rapid destruction of red blood cells. Fever (D) is a common symptom of a febrile non-hemolytic transfusion reaction. Other choices are incorrect as they are not specific to an allergic reaction.
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. Aspirin therapy
- B. Calcium supplements
- C. Estrogen therapy
- D. Thyroid hormones
Correct Answer: D
Rationale: The correct answer is D: Thyroid hormones. Excessive use of thyroid hormones can lead to osteoporosis by increasing bone turnover and reducing bone mineral density. Thyroid hormones can interfere with the normal process of bone formation and resorption, leading to weakened bones. Aspirin therapy (A) is not a risk factor for osteoporosis. Calcium supplements (B) are actually recommended to prevent osteoporosis. Estrogen therapy (C) is also not a risk factor; in fact, estrogen helps to maintain bone density.
A nurse assesses a client 2 hours after TURP. What indicates a complication?
- A. Clear urine output
- B. Burgundy-colored urine output
- C. Mild pain at the incision site
- D. Temperature of 98.6°F
Correct Answer: B
Rationale: The correct answer is B: Burgundy-colored urine output. This indicates a complication post-TURP due to potential bleeding. Clear urine output (A) is normal. Mild pain at the incision site (C) is expected. Temperature of 98.6°F (D) is within normal range.