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An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The patient reports feeling very weak and jittery. What actions should the nurse take?
- A. Check fingerstick glucose level.
- B. Assess skin temperature and moisture.
- C. Administer a PRN dose of regular insulin.
- D. Document anxiety on the surgical checklist.
- E. Measure pulse and blood pressure.
Correct Answer: A,B,E
Rationale: Checking fingerstick glucose, assessing skin temperature/moisture, and measuring pulse/blood pressure are critical to evaluate for hypoglycemia, a likely cause of weakness and jitteriness in a diabetic patient.
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A client arrives at the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Decrease the flow rate.
- B. Irrigate the catheter manually.
- C. Discontinue infusing solution.
- D. Monitor catheter drainage.
Correct Answer: B
Rationale: Manual irrigation dislodges blood clots, ensuring catheter patency and preventing urinary obstruction.
A patient with small cell carcinoma of the lung is admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The patient's serum sodium level increases from 120 mEq/L to 125 mEq/L as they respond to treatment. Based on this finding, what intervention should the nurse implement?
- A. Maintain the prescribed fluid restriction.
- B. Withhold the next scheduled dose of treatment.
- C. Increase neurologic checks to every 2 hours.
- D. Assess for increasing fluid volume overload.
Correct Answer: A
Rationale: Maintaining fluid restriction is key in SIADH to prevent further sodium dilution, supporting the patient's improving sodium levels.
An adult client who had a gastric bypass surgery is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are: temperature 38.3° C, heart rate 130 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client's plan of care?
- A. Monitor skin for breakdown.
- B. Strict intravenous (IV) fluid replacement.
- C. Encourage regular turning.
- D. Assess wound drainage daily.
Correct Answer: B
Rationale: Strict IV fluid replacement is critical to manage hypovolemia and prevent sepsis in suspected anastomosis leakage.
The nurse is caring for a patient with chronic pancreatitis who reports persistent gnawing abdominal pain. What assessment data is most important for the nurse to obtain to help manage the patient's pain?
- A. Activity level of bowel sounds.
- B. Level and amount of physical activity.
- C. Eating patterns of dietary intake.
- D. Color and consistency of feces.
Correct Answer: C
Rationale: Eating patterns identify foods that exacerbate pancreatitis pain, guiding dietary modifications.
Following a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan?
- A. Eliminate all spicy foods from your diet
- B. Drink 3 liters of water each day
- C. Clamp the catheter when taking a shower
- D. Avoid driving a car for 2 weeks
Correct Answer: B
Rationale: Drinking 3 liters of water daily flushes the bladder, reducing infection risk post-TURP.