Nokea
A patient who has just had a TURP asks his nurse to explain why he has to have the bladder irrigation because it seems to increase his pain. Which of the following explanations by the nurse is best?
- A. “The bladder irrigation is needed to stop the bleeding in the bladder.”
- B. “Antibiotics are being administered into the bladder to prevent infection.”
- C. “The irrigation is needed to keep the catheter from becoming occluded by blood clots.”
- D. “Normal production of urine is maintained with the irrigations until healing can occur.”
Correct Answer: C
Rationale: Step 1: The nurse should explain that bladder irrigation is necessary to prevent blood clots from occluding the catheter after a TURP procedure.
Step 2: Without irrigation, blood clots could block the catheter, leading to urinary retention and potential complications.
Step 3: This explanation addresses the patient's concern about increased pain and highlights the importance of the irrigation in maintaining proper urine flow.
Step 4: Choice A is incorrect because the primary purpose of irrigation is not to stop bleeding but to prevent clot formation. Choice B is incorrect because the irrigation is not for administering antibiotics. Choice D is incorrect as it does not address the issue of clot formation.
You may also like to solve these questions
A baby is born temporarily immune to the diseases to which the mother is immune. The nurse understands that this is an example of which of the following types of immunity?
- A. Naturally acquired passive immunity
- B. Naturally acquired active immunity
- C. Artificially acquired passive immunity
- D. Artificially acquired active immunity
Correct Answer: A
Rationale: The correct answer is A: Naturally acquired passive immunity. This type of immunity occurs when antibodies are passed from mother to baby through the placenta or breast milk, providing temporary protection. The baby does not produce its antibodies, hence it is passive. Choice B, naturally acquired active immunity, involves the body producing its antibodies after exposure to a pathogen. Choice C, artificially acquired passive immunity, involves receiving preformed antibodies from an external source. Choice D, artificially acquired active immunity, involves the body producing antibodies in response to vaccination.
Which of the following is usually the first symptom of a cataract that the nurse would expect a patient to report during assessment?
- A. Dry eyes
- B. Blurring of vision
- C. Eye pain
- D. Loss of peripheral vision
Correct Answer: B
Rationale: The correct answer is B: Blurring of vision. This is typically the first symptom of a cataract because the clouding of the lens causes light to scatter, leading to blurred vision. Dry eyes (A) and eye pain (C) are not typically associated with cataracts. Loss of peripheral vision (D) is more commonly seen in conditions like glaucoma. In summary, blurring of vision is the hallmark symptom of cataracts due to lens clouding, distinguishing it from other eye conditions.
The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
- A. Limit visits by family members
- B. Encourage the client to use a wheelchair
- C. Use the smallest needle possible for injections
- D. Maintain accurate fluid intake and output records
Correct Answer: C
Rationale: The correct answer is C: Use the smallest needle possible for injections. This is important for a client with thrombocytopenia because they have a low platelet count, leading to an increased risk of bleeding. Using a small needle minimizes the risk of causing bleeding or bruising during injections. Limiting family visits (choice A) is not directly related to protecting the client from bleeding. Encouraging wheelchair use (choice B) is not specifically relevant to protecting the client with thrombocytopenia. Maintaining accurate fluid intake and output records (choice D) is important but not directly related to preventing bleeding in a client with thrombocytopenia.
Which nursing interventions can help prevent falls in a patient with Parkinson’s disease? Choose all answers that are correct. i.Keep the patient’s call light within reach ii.Apply a soft vest restraint when the patient is in bed iii.Avoid use of throw rugs iv.Maintain the patient’s bed in a low position v.Encourage the patient to be independent for as long as possible vi.Provide a cane or walker for ambulation
- A. 1, 4, 2005
- B. 1, 3, 4, 6
- C. 2, 3, 2006
- D. 2, 4, 5, 6
Correct Answer: A
Rationale: The correct answers are i. Keep the patient’s call light within reach, iii. Avoid use of throw rugs, and iv. Maintain the patient’s bed in a low position.
1. Keeping the call light within reach ensures the patient can easily call for assistance, reducing the risk of falls.
2. Avoiding throw rugs prevents tripping hazards that can lead to falls.
3. Maintaining the bed in a low position reduces the risk of injury if the patient falls out of bed.
The incorrect choices:
- Choice B includes answer 3 (Avoid use of throw rugs), which is correct, but also includes answer 6 (Provide a cane or walker for ambulation), which is not specific to fall prevention.
- Choice C includes answer 2 (Apply a soft vest restraint when the patient is in bed), which can increase the risk of falls due to restricted movement.
- Choice D includes answers that are not directly related to fall prevention, such as 2 (Apply a soft vest
Patients are at risk for overwhelming postsplenectomy infection (OPSI) following splenectomy. Which of the ff. symptoms alerts the nurse to this possibility?
- A. Bruising around the operative site
- B. Pain
- C. Irritability
- D. Fever
Correct Answer: D
Rationale: The correct answer is D: Fever. Following splenectomy, patients are at risk for OPSI due to impaired immune response. Fever is a key symptom of infection and should alert the nurse to this possibility. Bruising around the operative site (A) is expected post-surgery. Pain (B) is common after surgery and may not specifically indicate OPSI. Irritability (C) is a vague symptom and not specific to OPSI. In summary, fever is the most concerning symptom as it can indicate an underlying infection in a postsplenectomy patient.