Nokea
The client is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which finding indicates that the bladder irrigation is effective?
- A. The client reports minimal pain and discomfort.
- B. The urine appears clear and free of clots.
- C. The client has no signs of infection.
- D. The client is able to void independently.
Correct Answer: B
Rationale: The presence of clear urine free of clots is an indicator that the bladder irrigation is effective. This finding suggests that the irrigation is preventing clot formation and ensuring proper drainage, which is crucial after a TURP procedure. The client reporting minimal pain and discomfort (choice A) may be a positive sign but does not directly reflect the effectiveness of the bladder irrigation. The absence of infection signs (choice C) is important but not specific to evaluating the bladder irrigation. The client being able to void independently (choice D) is a good sign overall but does not specifically indicate the effectiveness of the bladder irrigation.
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The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient?
- A. Obtain assistance and physically transfer the patient to the chair.
- B. Assist with ambulation and measure how far the patient walks.
- C. Give pain medication after ambulation so the patient will have a clear mind.
- D. Bring the patient to the cafeteria for group instruction on ambulation.
Correct Answer: B
Rationale: The most appropriate nursing intervention for this patient is to assist with ambulation and measure how far the patient walks. This intervention helps quantify the patient's progress in mobility and rehabilitation. Choice A is incorrect because physically transferring the patient does not focus on promoting independence or assessing progress. Choice C is inappropriate as pain medication should be given based on scheduled times or as needed, not specifically after ambulation. Choice D is not suitable as group instruction on ambulation is not as individualized or focused on the patient's current needs and abilities.
While reviewing the medical records of a client with a pressure ulcer, a nurse should expect which of the following findings?
- A. Albumin level of 3 g/dL
- B. Hemoglobin level of 12 g/dL
- C. WBC count of 6,000/mm³
- D. Blood glucose level of 100 mg/dL
Correct Answer: A
Rationale: An albumin level below 3.5 g/dL indicates protein deficiency, which can impair wound healing and contribute to pressure ulcer formation. Hemoglobin level and WBC count are not directly associated with pressure ulcers. Blood glucose level, while important for overall health, is not specifically linked to pressure ulcer development.
An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first?
- A. Establish a toileting schedule to decrease episodes of incontinence
- B. Complete a functional assessment of the client's self-care abilities
- C. Apply a barrier ointment to intact areas that may be exposed to moisture
- D. Determine the size and depth of skin breakdown over the sacral area
Correct Answer: D
Rationale: The first action the nurse should implement is to determine the size and depth of the skin breakdown over the sacral area. This initial assessment will provide crucial information on the extent of the damage and guide appropriate care interventions. Option A is not the priority in this scenario as the immediate concern is addressing the existing skin breakdown. Option B, completing a functional assessment, is important but should come after addressing the acute issue of skin breakdown. Option C, applying a barrier ointment, may be beneficial later but does not address the primary need of assessing the extent of the current skin damage.
A patient's neighbor is scheduled for elective surgery. The neighbor's provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest?
- A. Avoid the blood transfusion
- B. Donate autologous blood before the surgery
- C. Use a blood substitute
- D. Take antibiotics before the surgery
Correct Answer: B
Rationale: Donating autologous blood before surgery is an appropriate suggestion by the nurse. This process involves the patient donating their own blood before the surgery, which reduces the risk of infection from transfusions as the patient is receiving their own blood. Choice A is incorrect as avoiding the blood transfusion may not be feasible or safe in the context of expected blood loss during surgery. Choice C is not a common practice and may carry its own risks. Choice D is not directly related to reducing the risk of infection from a blood transfusion.
A client with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?
- A. Encourage the client to increase fluid intake.
- B. Monitor the client's blood glucose level.
- C. Administer insulin as prescribed.
- D. Assess the client's urine output.
Correct Answer: B
Rationale: The correct answer is to monitor the client's blood glucose level. When a client with diabetes mellitus presents with symptoms of polyuria, polydipsia, and polyphagia, it indicates hyperglycemia. Monitoring blood glucose levels is crucial to assess and manage the client's condition effectively. Option A, encouraging the client to increase fluid intake, may exacerbate polyuria. Option C, administering insulin, should be done based on the healthcare provider's prescription after assessing the blood glucose level. Option D, assessing the client's urine output, is important but not the most immediate action needed in this scenario; monitoring blood glucose levels takes precedence.