Nokea
The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement? Select all that apply.
- A. Assess the urine in the continuous irrigation drainage bag.
- B. Decrease the irrigation fluid in the continuous irrigation catheter.
- C. Lower the head of the bed while raising the foot of the bed.
- D. Contact the surgeon to give an update on the client’s condition.
- E. Check the client’s postoperative creatinine and BUN.
Correct Answer: A,C,D
Rationale: Tachycardia, hypotension, and clammy skin suggest hypovolemic shock, likely from bleeding. Assess urine for blood, use Trendelenburg to improve perfusion, and notify the surgeon. Decreasing irrigation may worsen clotting, and lab checks are less urgent.
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The nurse performs bladder irrigation through an indwelling catheter. The nurse instilled 90 mL of sterile normal saline. The catheter drained 710 mL. What is the client’s output?
Correct Answer: 620 mL
Rationale: Urine output = Total drainage - Irrigation fluid instilled = 710 mL - 90 mL = 620 mL. This isolates the client’s actual urine production from the irrigation fluid.
Which assessment before and after peritoneal dialysis is most valuable in evaluating the outcome of treatment?
- A. Pulse rate
- B. Body weight
- C. A Abdominal girth
- D. Urine output
Correct Answer: B
Rationale: Body weight is the most valuable assessment, as weight loss after dialysis indicates effective removal of excess fluid.
To avoid erroneous test results caused by the manipulation of the prostate, the nurse should be included in diagnostic test before the client's rectal examination?
- A. Kidneys, ureters, bladder X-ray
- B. Needle biopsy of the prostate gland
- C. Prostate specific antigen (PSA) test
- D. Transrectal ultrasound examination
Correct Answer: C
Rationale: The PSA test should be done before rectal examination, as manipulation can elevate PSA levels, leading to false results.
The elderly client is diagnosed with chronic glomerulonephritis. Which laboratory value indicates to the nurse the condition has become worse?
- A. The blood urea nitrogen is 15 mg/dL.
- B. The creatinine level is 1.2 mg/dL.
- C. The glomerular filtration rate is 40 mL/min.
- D. The 24-hour creatinine clearance is 100 mL/min.
Correct Answer: C
Rationale: A GFR of 40 mL/min indicates significant renal impairment, suggesting worsening chronic glomerulonephritis. Normal BUN (15 mg/dL), creatinine (1.2 mg/dL), and creatinine clearance (100 mL/min) do not reflect deterioration.
Which client should the nurse not assign to a UAP working on a surgical floor?
- A. The client with a suprapubic catheter inserted yesterday.
- B. The client who has had an indwelling catheter for the past week.
- C. The client who is on a bladder-training regimen.
- D. The client who had a catheter removed this morning and is being discharged.
Correct Answer: C
Rationale: A client on a bladder-training regimen requires nursing judgment to assess progress and adjust the plan, which is outside the UAP’s scope. Routine catheter care or post-removal care can be assigned.