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A nurse is teaching a client about cystoscopy preparation. What instruction should be included?
- A. Fast for 8 hours before the procedure.
- B. Drink plenty of water before the test.
- C. Expect to stay overnight in the hospital.
- D. Empty the bladder before the procedure.
Correct Answer: D
Rationale: Emptying the bladder ensures a clear view during cystoscopy and reduces discomfort.
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The nurse is caring for a client requiring an emergent transfusion of packed red blood cells. The nurse checks the blood bank, but the only available blood is O + (positive). The client's blood type is A+ (positive). What is the nurse's most appropriate action?
- A. Arrange for a cross-match between the available blood and the client's blood.
- B. Call the other blood banks and ask if they have blood units available with the client’s blood type.
- C. Notify the physician that there is no available blood in the blood bank.
- D. Call the client’s family and tell them that he needs blood.
Correct Answer: A
Rationale: In an emergency, O+ blood can be safely transfused to an A+ client, as O+ is the universal donor for red blood cells. Arranging for a cross-match ensures compatibility and is the most appropriate action. Contacting other blood banks or notifying the physician delays care, and calling the family is inappropriate.
A client had a colectomy 8½ hours ago. She has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
- A. Check that the family is comfortable.
- B. Assess vital signs following the use of morphine.
- C. Dim the lights in the room.
- D. Increase nasal oxygen from 2 to 3 L.
Correct Answer: B
Rationale: Morphine can cause respiratory depression or hypotension. Assessing vital signs after PCA use ensures the client's safety and detects adverse effects promptly.
What is the priority nursing action for a client with a suspected brain tumor?
- A. Administer pain medication.
- B. Monitor neurological status.
- C. Provide emotional support.
- D. Restrict physical activity.
Correct Answer: B
Rationale: Monitoring neurological status is the priority to detect changes associated with a brain tumor.
The nurse is assessing a client for neurologic impairment after a total hip replacement. Which of the following would indicate impairment in the affected extremity?
- A. Decreased distal pulse.
- B. Inability to move.
- C. Diminished capillary refill.
- D. Coolness to the touch.
Correct Answer: B
Rationale: Inability to move suggests nerve damage, a serious complication requiring immediate evaluation.
A client with peripheral vascular disease has chronic, severe pretibial and ankle edema bilaterally. Because the client is on complete bed rest and circulation is compromised, one goal is to maintain tissue integrity. Which of the following interventions will help achieve this outcome?
- A. Administering pain medication
- B. Encouraging fluids
- C. Turning the client every 1 to 2 hours
- D. Maintaining hygiene
Correct Answer: C
Rationale: Turning the client every 1 to 2 hours prevents pressure ulcers by relieving pressure on dependent areas, promoting circulation, and maintaining skin integrity in a client with PVD and edema on bed rest. Pain medication, fluids, and hygiene are important but do not directly address tissue integrity.