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A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
- A. Restrict the client’s oral fluid intake.
- B. Remind the client he might feel a constant urge to void.
- C. Weigh the client every evening.
- D. Monitor the client’s urine output every 6 hours.
Correct Answer: B
Rationale: The correct answer is B: Remind the client he might feel a constant urge to void. After a transurethral resection of the prostate, continuous bladder irrigation is often used to prevent blood clots and ensure urine output. This procedure can cause the client to feel a constant urge to void due to the bladder being continuously filled and emptied. Therefore, reminding the client about this sensation can help alleviate anxiety and discomfort.
Choice A: Restricting the client's oral fluid intake is incorrect because maintaining hydration is essential postoperatively to prevent complications such as dehydration and urinary retention.
Choice C: Weighing the client every evening is unnecessary and not directly related to the care of a client post transurethral resection of the prostate.
Choice D: Monitoring the client's urine output every 6 hours is important, but reminding the client about the sensation of constant urge to void takes priority in this scenario.
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A nurse is caring for a client who is postpartum and asks the nurse when her breast milk will 'come in.' Which of the following responses should the nurse make?
- A. Within 2 days.
- B. In 3 to 5 days.
- C. In about 10 days.
- D. In 6 to 8 days.
Correct Answer: B
Rationale: The correct answer is B: In 3 to 5 days. This is because breast milk typically comes in around 3 to 5 days after giving birth, as it takes time for hormonal changes to trigger milk production. Option A (Within 2 days) is too soon for most women to experience lactogenesis II. Option C (In about 10 days) and Option D (In 6 to 8 days) are both incorrect as they are outside the typical timeframe for milk production to start. It's important for the nurse to provide accurate information to the client to manage her expectations and provide proper support during this crucial time.
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?
- A. Family history of cardiac disease.
- B. Increasing age.
- C. Diagnosis of diabetes mellitus.
- D. Cigarette smoking.
Correct Answer: D
Rationale: The correct answer is D: Cigarette smoking. Smoking is a modifiable risk factor for cardiovascular disease as individuals can quit smoking to reduce their risk. Family history (A) and increasing age (B) are non-modifiable risk factors. Diabetes (C) is a risk factor but not modifiable in this context. Other choices not provided.
A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
- A. Induce sedation.
- B. Suppress respiratory effort.
- C. Decrease chest wall compliance.
- D. Decrease respiratory secretions.
Correct Answer: B
Rationale: The correct answer is B: Suppress respiratory effort. Pancuronium is a neuromuscular blocking agent that paralyzes skeletal muscles, including the muscles involved in breathing. In ARDS, the client may have difficulty breathing due to lung damage, so pancuronium can be used to facilitate mechanical ventilation by preventing respiratory muscle movement. This allows the ventilator to control the client's breathing without interference. The other choices are incorrect because pancuronium does not induce sedation (A), affect chest wall compliance (C), or decrease respiratory secretions (D). It solely works to suppress respiratory effort by blocking neuromuscular transmission.
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
- A. Hemorrhage
- B. Infection
- C. Urinary retention
- D. Pain
Correct Answer: A
Rationale: The correct answer is A: Hemorrhage. Postoperative hemorrhage is a critical complication following a transurethral resection of the prostate due to the rich blood supply in the area. It can lead to hypovolemic shock and requires immediate intervention to prevent further complications. Monitoring for signs of bleeding such as increased heart rate, decreased blood pressure, and decreased urine output is crucial.
B: Infection is an important complication to monitor for but is not as immediately life-threatening as hemorrhage.
C: Urinary retention can occur postoperatively but is not as urgent as hemorrhage.
D: Pain management is important for the client's comfort, but it is not the priority in this situation.
In summary, monitoring for hemorrhage is crucial as it is the most life-threatening complication that requires immediate attention compared to the other options.
A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?
- A. Vesicles on the skin
- B. Respiratory failure
- C. Flu-like symptoms
- D. Coughing of blood
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Inhalation anthrax primarily affects the respiratory system, causing symptoms such as difficulty breathing, cough, and chest discomfort. Respiratory failure can occur in severe cases. Vesicles on the skin (A) are not typically associated with inhalation anthrax. Flu-like symptoms (C) are nonspecific and can be seen with various infections. Coughing of blood (D) is not a common symptom of inhalation anthrax. Therefore, the most indicative finding of possible exposure to inhalation anthrax is respiratory failure.