Nokea
An 80-year-old client had spinal anesthesia for a transurethral resection of the prostate and received 4,000 mL of room temperature isotonic bladder irrigation. He now has continuous irrigation through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most important to include in his plan of care?
- A. Empty the catheter drainage bag.
- B. Cover the client with warm blankets.
- C. Hang new bags of irrigation.
- D. Turn the client.
Correct Answer: B
Rationale: Room-temperature irrigation can cause hypothermia, especially in an elderly client. Covering with warm blankets is the most important intervention to maintain normothermia.
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The nurse should do which of the following to decrease a female client's anxiety about being placed in the lithotomy position for surgery?
- A. Explain in detail what will occur in the operating room.
- B. Determine what the client is concerned about.
- C. Pad the stirrups for comfort.
- D. Reassure the client that an all-female surgical team will be present.
Correct Answer: B
Rationale: Determining the client's specific concerns about the lithotomy position allows the nurse to address her anxiety directly, promoting trust and tailored reassurance.
An 82-year-old female has several ecchymotic areas on her left arm. The nurse should further assess the client for:
- A. Elder abuse.
- B. Self-inflicted injury.
- C. Increased capillary fragility and permeability.
- D. Increased blood supply to the skin.
Correct Answer: C
Rationale: Aging increases capillary fragility and permeability, leading to easy bruising (ecchymosis). While elder abuse is possible, capillary fragility is the most likely cause in this context.
Which of the following should the nurse interpret as an indication of a complication after the first few days of TPN therapy?
- A. Glycosuria.
- B. A 1- to 2-pound weight gain.
- C. Decreased appetite.
- D. Elevated temperature.
Correct Answer: D
Rationale: An elevated temperature after the first few days of TPN may indicate a complication like infection, particularly catheter-related. Glycosuria can occur with TPN but is managed, a small weight gain is expected, and decreased appetite is not a direct complication. CN: Pharmacological and parenteral therapies; CL: Analyze
A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia (PCA) system with morphine sulfate. Which of the following actions is a priority nursing intervention for the client?
- A. Observing the client at regular intervals for opioid addiction.
- B. Encouraging the client to reduce analgesic use and tolerate the pain.
- C. Evaluating pain control at least every 2 hours.
- D. Increasing the amount of morphine if the client does not administer the medication.
Correct Answer: C
Rationale: Regularly evaluating pain control ensures adequate relief while monitoring for side effects, a priority in PCA management.
The nurse using healing touch affects a client's pain primarily through:
- A. Energy fields.
- B. Touch therapy.
- C. Massage.
- D. Hypnosis.
Correct Answer: A
Rationale: Healing touch primarily uses energy fields to promote relaxation and pain relief, distinct from massage, physical touch therapy, or hypnosis.