Nokea
A nurse is reinforcing teaching with an older adult client who is postoperative following a transurethral resection of the prostate. Which of the following statements should the nurse include in the teaching?
- A. You should take ibuprofen for discomfort.
- B. You should wait 6 weeks before resuming sexual intercourse.
- C. You may tub bathe until the catheter is removed.
- D. You may drive after 1 week.
- E. Avoid drinking water.
- F. Expect bright red urine indefinitely.
- G. Ignore bladder spasms.
Correct Answer: B
Rationale: Waiting 6 weeks allows healing; ibuprofen may increase bleeding, tub baths risk infection, and driving depends on recovery.
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A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the following interventions should the nurse include?
- A. Obtain the client's rectal temperature every 4 hr.
- B. Prohibit fresh flowers in the client's room.
- C. Encourage the client to eat a low-protein diet.
- D. Initiate airborne precautions for the client.
- E. Monitor daily CBC.
- F. Limit visitors.
- G. Use strict hand hygiene.
Correct Answer: B
Rationale: Fresh flowers can harbor bacteria, increasing infection risk in neutropenia; rectal temps risk injury, and airborne isn't needed.
A nurse is collecting data from a client who had a bronchoscopy. Which of the following findings should the nurse report to the provider?
- A. Sore throat
- B. Blood pressure 110/78 mm Hg
- C. Presence of gag reflex
- D. Facial edema
Correct Answer: D
Rationale: Post-bronchoscopy, nurses monitor for complications like bleeding, infection, or airway issues. Option A, sore throat, is a common, benign side effect from the scope, not requiring immediate reporting. Option B, blood pressure 110/78 mm Hg, is normal and stable, needing no action. Option C, presence of gag reflex, is reassuring it indicates airway protection is intact post-sedation, a positive sign. Option D, facial edema, is correct to report it's abnormal and could signal an allergic reaction to sedation, airway swelling, or trauma from the procedure, potentially compromising breathing. This finding demands urgent provider evaluation to rule out anaphylaxis or obstruction, aligning with airway management priorities. While sore throat and gag reflex are expected, facial edema deviates from the norm, requiring swift intervention to prevent escalation, making it the critical finding to escalate.
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
- A. Limit the client's physical activity until bowel continence is achieved.
- B. Assist the client to the restroom 30 min after meals.
- C. Instruct the client to limit their intake of high-fiber foods.
- D. Limit the client's fluid intake to 1500 mL/day
Correct Answer: B
Rationale: Bowel training aims to establish a regular pattern for defecation, particularly for clients with fecal incontinence, by leveraging the gastrocolic reflex, which increases intestinal motility after meals. Option A is incorrect because limiting physical activity does not promote bowel regularity and may worsen incontinence by reducing muscle tone. Option B is correct as assisting the client to the restroom 30 minutes after meals takes advantage of this reflex, encouraging predictable bowel movements and enhancing control over time. Option C is wrong since high-fiber foods aid bowel regularity by adding bulk to stool, which helps with continence, not hinders it. Option D is also incorrect adequate fluid intake (not restriction to 1500 mL/day) supports healthy stool consistency and prevents constipation, a key factor in incontinence management. Assisting post-meal aligns with physiological principles and patient-centered care, making it the best intervention for effective bowel training.
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
- A. Keep both arms below the level of the client's heart.
- B. Limit range-of-motion exercises with the affected arm.
- C. Use the client's left arm to obtain blood samples.
- D. Obtain blood pressure readings using the client's right arm.
Correct Answer: C
Rationale: Using the unaffected (left) arm for blood samples prevents trauma to the right arm, reducing the risk of lymphedema after a radical mastectomy. The affected arm should be elevated, exercised appropriately, and avoided for procedures like blood pressure readings.
A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?
- A. Distended neck veins
- B. Polyuria
- C. Vomiting
- D. Hypertension
- E. Fever and chills
- F. Tachycardia
- G. Hypotension
Correct Answer: C
Rationale: Vomiting is a sign of a septic reaction due to contaminated blood; distended veins suggest fluid overload, polyuria isn't typical, and hypertension isn't specific.