Nokea
Eight hours after surgery, a client has a distended bladder and is unable to void. Which of the following is the most appropriate nursing action?
- A. Insert a straight catheter.
- B. Increase I.V. fluids.
- C. Notify the surgeon.
- D. Assist the client to the bathroom.
Correct Answer: A
Rationale: A distended bladder and inability to void suggest urinary retention, common post-surgery. Inserting a straight catheter relieves the bladder and prevents complications like overdistension.
You may also like to solve these questions
The nurse should assess the client with bladder cancer for which of the following?
- A. Suprapubic pain.
- B. Dysuria.
- C. Painless hematuria.
- D. Urine retention.
Correct Answer: C
Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often presenting as the initial sign due to tumor growth causing bleeding without associated pain.
A client who has had a lumbar laminectomy with a spinal fusion is sitting in a chair. In which position are his feet if he is complying with his postoperative instructions?
- A. On the floor with the feet flat.
- B. On a low footstool.
- C. In any comfortable position with legs uncrossed.
- D. On a high footstool so the feet are level with the chair seat.
Correct Answer: A
Rationale: Feet flat on the floor maintain neutral spine alignment, reducing strain on the surgical site.
A 58-year-old female with a family history of CAD is being seen for the annual physical examination. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse?
- A. The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet.'
- B. The triglycerides are elevated and will be lowered to normal with these medications.'
- C. The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered.'
- D. The medications are not indicated since your lab values are all normal.'
Correct Answer: C
Rationale: Elevated CRP (4.2) indicates inflammation associated with cardiovascular risk. Statins and aspirin reduce inflammation and prevent cardiovascular events, addressing the client's risk profile.
The client is a survivor of non-Hodgkin's lymphoma. Which of the following statements indicates the client needs additional information?
- A. Regular screening is very important for me.'
- B. The survivor rate is directly proportional to the incidence of second malignancy.'
- C. The survivor rate is indirectly proportional to the incidence of second malignancy.'
- D. It is important for survivors to know the stage of the disease and their current treatment plan.'
Correct Answer: B
Rationale: The survival rate for non-Hodgkin's lymphoma is inversely proportional to the incidence of second malignancies, as secondary cancers reduce survival. The statement that it is directly proportional indicates a misunderstanding. Regular screening, knowing disease stage, and treatment plans are correct.
A client with renal calculi is prescribed potassium citrate. The purpose is to:
- A. Dissolve stones.
- B. Alkalinize urine.
- C. Reduce pain.
- D. Prevent bleeding.
Correct Answer: B
Rationale: Potassium citrate alkalinizes urine, preventing uric acid stone formation.