Nokea
The nurse is calculating the intake and output for a client who had a transurethral prostatectomy and is receiving continuous bladder irrigation at 175 mL/hr. The nurse empties 2300 mL of urine from the urinary drainage bag at the end of the 8-hour shift. How many mL should the nurse document as the client's net urine output for the shift? Record your answer using a whole number.
- A. 900 mL
Correct Answer: A
Rationale: Irrigation input = 175 mL/hr × 8 hr = 1400 mL. Total output = 2300 mL. Net urine output = 2300 mL - 1400 mL = 900 mL.
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There is a train wreck causing 46 casualties. The nurse is asking personnel on the floor to suggest clients who could be discharged to make room for casualties. Which client would be best for the LPN to suggest?
- A. A 77-year-old who had a fractured femur with hip replacement yesterday
- B. A 58-year-old who had an open cholecystectomy two days ago
- C. A 52-year-old who had a bowel resection with colostomy yesterday
- D. A 44-year-old who is undergoing internal radiation for cancer of the cervix
Correct Answer: B
Rationale: The client who had an open cholecystectomy two days ago is likely stable and closer to discharge compared to those with recent major surgeries or ongoing radiation, which require specialized care.
A client with throat cancer receives radiation therapy to the head and neck. Which of the following strategies are appropriate to decrease the adverse effects associated with radiation therapy? Select all that apply.
- A. Avoid irritants such as acidic, spicy foods
- B. Discourage the use of topical analgesics
- C. Encourage liquid nutritional supplements
- D. Perform oral hygiene once per day
- E. Use artificial saliva to control dryness
Correct Answer: A,C,E
Rationale: Avoiding irritants reduces mucosal irritation. Liquid supplements ensure adequate nutrition when swallowing is difficult. E: Artificial saliva alleviates xerostomia, a common side effect. B is incorrect as topical analgesics may be beneficial for pain relief. D is incorrect as frequent oral hygiene is needed to prevent infections and maintain oral health.
A client with seizure disorder has an order for Dilantin (Phenytoin). Which of the following is not a side effect of Dilantin (Phenytoin)?
- A. Gingival hypertrophy
- B. Insomnia
- C. Diarrhea
- D. Slurred speech
Correct Answer: B
Rationale: Dilantin causes gingival hypertrophy, slurred speech, and occasionally diarrhea, but insomnia is not a common side effect.
The nurse is planning care for a 6-month-old client admitted with bacterial meningitis. Which nursing action is the priority?
- A. Apply padding to the crib side rails
- B. Document head circumference daily
- C. Implement a low-stimuli environment
- D. Initiate antibiotic therapy as prescribed
Correct Answer: D
Rationale: Prompt antibiotic therapy is critical to treat bacterial meningitis and prevent complications or death, making it the priority. A, B, and C are important but secondary; padding prevents injury, daily head circumference monitors for hydrocephalus, and a low-stimuli environment reduces seizure risk, but none address the infection directly.
A client has had a positive reaction to purified protein derivative (PPD). The client asks the nurse what this means. The nurse should indicate that the client has
- A. active tuberculosis
- B. been exposed to mycobacterium tuberculosis
- C. never had tuberculosis
- D. never been infected with mycobacterium tuberculosis
Correct Answer: B
Rationale: The PPD skin test is used to determine the presence of tuberculosis antibodies and a positive result indicates that the person has been exposed to mycobacterium tuberculosis. Additional tests are needed to determine if active tuberculosis is present.