Nokea
A nurse is evaluating a patient who is suffering from prostatic hypertrophy. What symptoms associated with urinary retention should the nurse anticipate? What symptoms of urinary retention should the nurse anticipate?
- A. Sensation of pressure
- B. Dysuria
- C. Bladder distension
- D. Tenderness over the symphysis pubis
Correct Answer: A,B,C,D
Rationale: The correct answer includes symptoms associated with urinary retention in a patient with prostatic hypertrophy. A: Sensation of pressure is expected due to the bladder being unable to empty completely. B: Dysuria can occur as the bladder becomes overfilled. C: Bladder distension is a common symptom as the bladder fills up but cannot empty fully. D: Tenderness over the symphysis pubis may be present due to the pressure on surrounding structures. Other choices are incorrect as they do not directly relate to urinary retention symptoms in this context.
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A nurse is administering an oral medication to an older adult patient. The patient states, 'The pill I always take is green. I don't take an orange pill.' What should the nurse respond? What should the nurse respond to a pill color concern?
- A. This is the medication that your doctor wants you to take.
- B. Sometimes the same pill comes in a different color.
- C. I will check your medication order again.
- D. Let me explain the purpose of the medication.
Correct Answer: C
Rationale: The correct answer is C: I will check your medication order again. The nurse should respond this way because the patient is confused about the color of the pill, indicating a potential medication error. By checking the medication order again, the nurse can ensure that the patient receives the correct medication. Choice A does not address the patient's concern about the pill color. Choice B may confuse the patient further and does not address the potential error. Choice D is not relevant to the patient's immediate concern about the pill color.
A nurse is caring for a patient who has a new prescription for amitriptyline. Which of the following adverse effects should the nurse monitor for? Which adverse effect should the nurse monitor for amitriptyline?
- A. Constipation
- B. Hypertension
- C. Fever
- D. Tachypnea
Correct Answer: A
Rationale: The correct answer is A: Constipation. Amitriptyline, a tricyclic antidepressant, can cause anticholinergic effects leading to constipation. The rationale is that amitriptyline blocks the action of acetylcholine in the gut, slowing down bowel movements and causing constipation. Monitoring for constipation is important to prevent complications such as fecal impaction. Choices B, C, and D are incorrect as hypertension, fever, and tachypnea are not commonly associated with amitriptyline use.
A nurse is caring for a patient who is 9 days postoperative following a total laryngectomy. The nurse removes the patient's NG tube and initiates oral feedings. Which of the following statements should the nurse make? Which statement should the nurse make post-laryngectomy?
- A. You should have no trouble swallowing fluids.
- B. It is no longer possible for you to choke on or aspirate food.
- C. I will add a thickener to your liquids to prevent aspiration.
- D. Tuck your chin when you swallow so you won't choke.
Correct Answer: D
Rationale: The correct answer is D: "Tuck your chin when you swallow so you won't choke." After a laryngectomy, patients have altered anatomy that can affect swallowing. Tucking the chin helps close off the airway during swallowing, reducing the risk of choking. This technique directs the food towards the esophagus instead of the trachea, minimizing the risk of aspiration. Choices A, B, and C are incorrect because they do not address the specific swallowing precautions needed post-laryngectomy. Choice A assumes normal swallowing function, which may not be the case. Choice B is inaccurate as aspiration can still occur post-laryngectomy. Choice C is not specific to the patient's individual needs and may not be necessary.
A nurse is preparing to replace a nearly empty container of total parenteral nutrition (TPN) for a patient. There has been a delay in receiving the new TPN solution from the pharmacy. Which of the following solutions should the nurse infuse until the next TPN solution is available? Which solution should the nurse infuse during TPN delay?
- A. Lactated Ringer's.
- B. 0.9% sodium chloride.
- C. Sodium chloride.
- D. Dextrose 10% in water.
Correct Answer: D
Rationale: The correct answer is D: Dextrose 10% in water. During a delay in receiving TPN, it is important to provide a source of glucose to prevent hypoglycemia. Dextrose 10% in water provides a source of glucose for the patient. Lactated Ringer's (A) and 0.9% sodium chloride (B) are isotonic solutions but do not provide glucose. Sodium chloride (C) is a saline solution and does not provide any nutritional value. Therefore, Dextrose 10% in water is the most appropriate choice to prevent hypoglycemia in this situation.
A nurse in an emergency department is caring for a patient who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. What prescription should the nurse anticipate from the provider? What prescription should the nurse anticipate for DKA?
- A. Glucocorticoid medications.
- B. Dextrose 5% in 0.45% sodium chloride.
- C. Oral hypoglycemic medications.
- D. 0.9% sodium chloride IV bolus.
Correct Answer: D
Rationale: The correct answer is D: 0.9% sodium chloride IV bolus. In DKA, the primary concern is severe dehydration and electrolyte imbalances due to high blood glucose levels. 0.9% sodium chloride helps to rehydrate the patient and correct electrolyte imbalances. Glucocorticoids (A) are not typically used in the treatment of DKA. Dextrose 5% in 0.45% sodium chloride (B) would worsen hyperglycemia. Oral hypoglycemic medications (C) are not appropriate for managing acute DKA. Therefore, the nurse should anticipate the prescription of 0.9% sodium chloride IV bolus to address the immediate needs of the patient with DKA.