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The healthcare provider prescribes diagnostic tests for a patient whose chest x-ray indicates pneumonia. Which diagnostic test should the nurse prepare the patient for?
- A. Computerized tomography (CT) of the chest.
- B. Arterial blood gases (ABG).
- C. Sputum culture and sensitivity.
- D. Blood cultures.
Correct Answer: C
Rationale: A sputum culture and sensitivity test identifies the causative organism of pneumonia, guiding appropriate antibiotic therapy.
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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 client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Explain the need to limit intake of oral fluids to reduce client discomfort.
- B. Teach the client techniques for performing intermittent catheterization.
- C. Remind the client to practice pelvic floor (Kegel) exercises regularly.
- D. Provide a bedside commode for immediate use in the client's room.
Correct Answer: B
Rationale: Intermittent catheterization manages urinary retention effectively in multiple sclerosis, maintaining bladder health.
The nurse is providing discharge teaching to an older patient hospitalized for treatment of venous leg ulcers. What instructions should the nurse include in the teaching plan?
- A. The patient should eat a diet high in protein and vitamins A and C.
- B. The patient should keep their legs elevated when sitting or lying down.
- C. The patient should maintain as much bed rest as possible.
- D. The patient should inspect their ankles daily for areas of darkening skin.
- E. The patient should apply intermittent cold compresses four times daily.
Correct Answer: A,B,D
Rationale: A diet high in protein and vitamins A and C, leg elevation, and daily ankle inspections support healing and early detection of complications in venous leg ulcers.
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.
The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan?
- A. Eat a diet that is high in protein and vitamins A and C.
- B. Maintain bed rest as much as possible.
- C. Keep legs elevated when sitting or lying down.
- D. Inspect ankles daily for areas of darkening skin.
- E. Apply intermittent cold compresses four times daily.
Correct Answer: A,C,D
Rationale: A high-protein diet with vitamins A and C, leg elevation, and daily ankle inspections promote healing and monitor complications in venous leg ulcers.