Nokea
A post-TURP patient experiences dribbling following removal of his catheter. Which action should the nurse take?
- A. Have him restrict fluid intake to 1000 mL/day
- B. Teach him to perform Kegel’s exercises 10 to 20 times per hour
- C. Reinsert the Foley catheter until he regains urinary control
- D. Reassure him that incontinence never lasts more than a few days
Correct Answer: B
Rationale: The correct answer is B: Teach him to perform Kegel's exercises 10 to 20 times per hour. This is the appropriate action because Kegel's exercises help strengthen the pelvic floor muscles, which can improve urinary control and reduce dribbling post-TURP. Restricting fluid intake (A) is not necessary and may lead to dehydration. Reinserting the Foley catheter (C) is not recommended as it can increase the risk of infection. Reassuring the patient (D) without providing any intervention is not addressing the issue. Teaching Kegel's exercises is the most effective and non-invasive approach to manage post-TURP dribbling.
You may also like to solve these questions
Seven girls were victims of food poisoning after eating the sandwiches served at snack time. Which of the following statement are true regarding food poisoning?
- A. Symptoms include salivation, cramping, nausea, vomiting and diarrhea
- B. Foods that are handled and allowed to remain without refrigeration before eaten are most dangerous
- C. Cooking will destroy the organism and stop production of enterotoxin
- D. All are correct
Correct Answer: D
Rationale: Step 1: Symptoms of food poisoning typically include salivation, cramping, nausea, vomiting, and diarrhea, so statement A is correct.
Step 2: Food left unrefrigerated can lead to bacterial growth, making it more dangerous, so statement B is accurate.
Step 3: Cooking can kill harmful organisms and stop the production of toxins, supporting statement C.
Step 4: All three statements are true and collectively provide a comprehensive understanding of food poisoning, making option D the correct answer.
The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:
- A. “Alcohol is not contraindicated while taking this medication.”
- B. “Good oral hygiene is needed, including brushing and flossing.”
- C. “The medication dose may be self-adjusted depending on side effects.”
- D. “The morning dose of the medication should be taken before a serum drug level is drawn.”
Correct Answer: B
Rationale: The correct answer is B: "Good oral hygiene is needed, including brushing and flossing." This is because phenytoin (Dilantin) can cause gingival hyperplasia, a side effect that leads to overgrowth of gum tissue. Good oral hygiene practices, such as regular brushing and flossing, can help prevent or minimize this side effect.
Choice A is incorrect because alcohol is contraindicated while taking phenytoin as it can increase the risk of side effects and decrease the effectiveness of the medication.
Choice C is incorrect because medication doses should never be self-adjusted without consulting a healthcare provider, as this can lead to ineffective treatment or potential harm.
Choice D is incorrect because the timing of the morning dose in relation to drawing a serum drug level is not relevant to the client's understanding of medication instructions and does not address the specific side effect of gingival hyperplasia associated with phenytoin.
Which of the ff should the nurse include in the teaching plan of a client with acute bronchitis?
- A. Not coughing frequently
- B. Washing the hands frequently
- C. Consuming adequate calories
- D. Encouraging a semi-Fowler’s position
Correct Answer: B
Rationale: The correct answer is B: Washing the hands frequently. This is important for preventing the spread of infection, which is crucial in acute bronchitis. By washing hands frequently, the client can reduce the risk of transmitting the infection to others and prevent reinfection.
A: Not coughing frequently - While managing cough is important, it is not the most crucial aspect in the teaching plan for acute bronchitis.
C: Consuming adequate calories - While nutrition is important for overall health, it is not specifically related to the management of acute bronchitis.
D: Encouraging a semi-Fowler’s position - While this position can help with breathing, it is not the most important aspect in the teaching plan for acute bronchitis.
Which of the following is an intraoperative outcome for a patient undergoing an inguinal hernia repair?
- A. Verbalizes fears
- B. Demonstrates leg exercises
- C. Maintains skin integrity
- D. Explains deep breathing exercises
Correct Answer: C
Rationale: The correct answer is C: Maintains skin integrity. During inguinal hernia repair surgery, maintaining skin integrity is crucial to prevent infection and ensure proper wound healing. This outcome focuses on the physical aspect of the surgery and reflects the patient's skin condition postoperatively. Verbalizing fears (A) addresses emotional concerns, demonstrating leg exercises (B) is related to postoperative rehabilitation, and explaining deep breathing exercises (D) targets respiratory function, none of which directly assess the intraoperative outcome of skin integrity.
Once admitted to hospital the physician indicates that Mr. Gubatan is a paraplegic. The family asks the nurse what that means. The nurse explains that:
- A. Upper extremities are paralyzed
- B. Both lower and upper extremities are
- C. Lower extremities are paralyzed paralyzed
- D. One side of the body is paralyzed
Correct Answer: C
Rationale: Rationale for Correct Answer (C):
1. Paraplegia is a condition where both lower extremities are paralyzed.
2. The prefix "para-" means alongside or beside, indicating that both legs are affected.
3. The nurse would explain to the family that Mr. Gubatan has paralysis in his lower extremities only.
4. This aligns with the medical definition of paraplegia.
Summary of Incorrect Choices:
A. Upper extremities being paralyzed is not indicative of paraplegia, as paraplegia specifically refers to lower extremity paralysis.
B. Both lower and upper extremities being paralyzed is suggestive of quadriplegia, not paraplegia.
D. One side of the body being paralyzed describes hemiplegia, not paraplegia.