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The client who is postoperative TURP asks the nurse, 'When will I know if I will be able to have sex after my TURP?' Which response is most appropriate by the nurse?
- A. You seem anxious about your surgery.'
- B. Tell me about your fears of impotency.'
- C. Potency can return in six (6) to eight (8) weeks.'
- D. Did you ask your doctor about your concern?'
Correct Answer: C
Rationale: Sexual function typically resumes 6–8 weeks post-TURP, providing a direct and reassuring answer. Other responses avoid the question or assume anxiety without addressing the concern.
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Which nursing diagnosis is priority for the client who has undergone a TURP?
- A. Potential for sexual dysfunction.
- B. Potential for an altered body image.
- C. Potential for chronic infection.
- D. Potential for hemorrhage.
Correct Answer: D
Rationale: Hemorrhage is the priority post-TURP due to the risk of significant bleeding from the surgical site, which can be life-threatening. Sexual dysfunction, body image, and infection are secondary concerns.
When administering the bladder instillation containing the chemotherapeutic drug, which safety precaution is most important for the nurse to take?
- A. Wear two pairs of latex gloves.
- B. As a mass syringe for the drug.
- C. Avoid wearing clothing with long sleeves.
- D. Limit contact time with the client.
Correct Answer: A
Rationale: Wearing two pairs of latex gloves protects the nurse from exposure to the chemotherapeutic drug during instillation.
The elderly client presents to the emergency department complaining of burning on urination with an urgency to void, and a temperature of 99.8°F. Which intervention should the nurse implement first?
- A. Ask the client to provide a clean voided midstream urine for culture.
- B. Insert an 18-gauge peripheral IV catheter and start normal saline fluids.
- C. Arrange for the client to be admitted to the medical unit.
- D. Initiate the ordered intravenous antibiotic medication.
Correct Answer: A
Rationale: Burning, urgency, and low-grade fever suggest a UTI. A midstream urine culture is the first step to confirm the diagnosis and guide treatment. IV fluids, admission, or antibiotics follow after diagnostic confirmation.
The nurse is caring for a client diagnosed with rule-out nephrotic syndrome. Which intervention should be included in the plan of care?
- A. Monitor the urine for bright-red bleeding.
- B. Evaluate the calorie count of the 500-mg protein diet.
- C. Assess the client’s sacrum for dependent edema.
- D. Monitor for a high serum albumin level.
Correct Answer: C
Rationale: Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema, often dependent (e.g., in the sacrum in bedridden clients). Assessing for dependent edema is a key intervention to monitor disease progression or response to treatment. Bright-red bleeding is not typical, a 500-mg protein diet is incorrect, and high serum albumin is not expected.
If the client makes the following statements, which information is most important to report to the physician before the client undergoes an intravenous pyelography (IVP)?
- A. The barium they give me to drink causes me to have concentration.
- B. I have a low tolerance for pain during procedures.
- C. I had a reaction when my gallbladder was X-rayed before.
- D. I get claustrophobic when I am put into that big round machine.
Correct Answer: C
Rationale: A previous reaction to a contrast dye, as implied by the gallbladder X-ray reaction, indicates a potential allergy risk, which must be reported before IVP.