Nokea
After a transurethral resection of the prostate (TURP), a client has bloody urine output with large clots. The nurse implements the postoperative prescription to irrigate the indwelling catheter PRN to maintain the catheter's patency. Which action should the nurse implement?
- A. Clamp the catheter for 30 minutes prior to irrigating with saline
- B. Manually irrigate the catheter with sterile saline as prescribed
- C. Increase the client's oral fluid intake to flush out clots naturally
- D. Remove the catheter and notify the healthcare provider immediately
Correct Answer: A
Rationale: Clamping the catheter before irrigation prevents sudden fluid shifts and ensures that irrigation is performed effectively.
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The following are true of vitamin K:
- A. It is a water-soluble vitamin
- B. It is found mainly in red meat
- C. After infancy most is synthesised by the gut flora
- D. Low levels after birth may lead to intracerebral haemorrhage
Correct Answer: C
Rationale: Vitamin K is synthesized by gut flora after infancy. It is a fat-soluble vitamin, and low levels after birth can lead to hemorrhagic disease of the newborn.
Manifestations of endocarditis include all of the following EXCEPT
- A. Gottron nodules
- B. hematuria
- C. petechiae
- D. splenomegaly
Correct Answer: A
Rationale: Gottron nodules are associated with dermatomyositis, not endocarditis.
What does the nurse explain that a ventricular septal defect will allow?
- A. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis
- B. Blood to shunt right to left, causing decreased pulmonary flow and cyanosis
- C. No shunting because of high pressure in the left ventricle
- D. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume
Correct Answer: A
Rationale: Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.
A child born with Down syndrome should be evaluated for which associated cardiac manifestation?
- A. Congenital heart defect (CHD)
- B. Systemic hypertension
- C. Hyperlipidemia
- D. Cardiomyopathy
Correct Answer: A
Rationale: CHD is found frequently in children with Down syndrome.
The nurse is providing discharge instructions to a client who is receiving prednisone (Deltasone) 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider?
- A. Rapid weight gain
- B. Increased energy levels.
- C. Frequent headaches.
- D. Dry mouth.
Correct Answer: A
Rationale: Rapid weight gain may indicate fluid retention, a side effect of prednisone that requires medical evaluation.