Nokea
All of the following clients are on the unit. Which one is most likely to develop urinary retention?
- A. A woman who had a modified radical mastectomy yesterday
- B. A man who had an abdominal cholecystectomy this morning
- C. A woman who had an abdominal hysterectomy yesterday
- D. A man who had surgery for a ruptured appendix
Correct Answer: C
Rationale: Abdominal hysterectomy involves pelvic manipulation, increasing urinary retention risk due to bladder trauma or nerve disruption. Other surgeries pose lower risk.
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Laboratory reference ranges
Hematocrit
39%-59%
(0.39-0.59)
The nurse is collecting data from a 2-week-old client who has tetralogy of Fallot. Which of the following findings would be a priority to follow up?
- A. cyanosis resolves in the knee-chest position
- B. weight gain of 0.6 lb (0.27 kg) since birth
- C. hematocrit level of 67% (0.67)
- D. murmur noted on auscultation
Correct Answer: C
Rationale: Elevated hematocrit indicates polycythemia, a serious complication of tetralogy of Fallot. Knee-chest relief , weight gain , and murmurs are expected.
The client presents to the unit with complaints of shortness of breath. A tentative diagnosis of respiratory acidosis related to pneumonia is made. Which finding would support this diagnosis?
- A. $\mathrm{pH}$ of $7.45, \mathrm{CO}_2$ of $45, \mathrm{HCO}_3$ of 26
- B. $\mathrm{pH}$ of $7.35, \mathrm{CO}_2$ of $46, \mathrm{HCO}_3$ of 27
- C. $\mathrm{pH}$ of $7.34, \mathrm{CO}_2$ of $30, \mathrm{HCO}_3$ of 22
- D. $\mathrm{pH}$ of $7.44, \mathrm{CO}_2$ of $32, \mathrm{HCO}_3$ of 25
Correct Answer: B
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and elevated CO₂ (>45 mmHg) due to impaired gas exchange, as in pneumonia. Option B (pH 7.35, CO₂ 46, HCO₃ 27) is closest to this profile, with slight compensation. Options A, C, and D show normal or alkalotic pH or low CO₂.
Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct?
- A. It is to observe reactive service and product problem solving
- B. Improvement of the processes in a proactive, preventive mode is paramount
- C. A chart audits to find to the process in a proactive, preventive mode is paramount
- D. A flow chart to organize daily tasks is critical to the initial stages
Correct Answer: B
Rationale: Improvement of the processes in a proactive, preventive mode is paramount. Total quality management and continuous quality improvement have a major goal of identifying ways to do the right thing at the right time in the right way by proactive problem-solving.
A client who is scheduled for surgery today says to the nurse, 'Do you think I'll survive the surgery?' What is the best initial response for the nurse to give?
- A. Don't worry, your surgeon is good.'
- B. Tell me about your concerns.'
- C. I can call your clergyman.'
- D. We do a lot of these surgeries here; everything will be okay.'
Correct Answer: B
Rationale: Exploring concerns validates the client's fears, fostering trust and addressing anxiety therapeutically.
Divalproex sodium (Depakote) is prescribed for a 28-year-old female. Which lab test would the nurse expect prior to administration of the medication?
- A. Urine drug screen
- B. Pregnancy test
- C. CBC with differential
- D. Liver function tests
Correct Answer: B
Rationale: Divalproex is teratogenic; a pregnancy test is critical in females of childbearing age to prevent fetal harm.