Nokea
The nurse is caring for a client following a transurethral resection of the prostate (TURP). Which finding should be reported to the physician immediately?
- A. Bright red urine 12 hours post-op
- B. Urine output of 30 mL/hour
- C. Complaints of bladder spasms
- D. Temperature of 100.2°F
Correct Answer: A
Rationale: Bright red urine 12 hours post-TURP suggests active bleeding, abnormal beyond initial pink-tinged output, requiring immediate physician report low output, spasms, or mild fever are less urgent. Nurses flag this, as hemorrhage risks clot retention or shock, prompting irrigation or intervention.
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The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a client with pancreatitis. Which role best fit that statement?
- A. Change agent
- B. Client advocate
- C. Case manager
- D. Collaborator
Correct Answer: B
Rationale: Questioning an inappropriate order like morphine for pancreatitis, which worsens sphincter of Oddi spasm reflects the client advocate role. Nurses protect patient rights and safety by challenging harmful directives, ensuring optimal care (e.g., suggesting alternatives like meperidine). This differs from change agent (lifestyle shifts), case manager (coordination), or collaborator (teamwork), emphasizing advocacy's focus on patient well-being, a core ethical duty in nursing.
Which of the following statement is TRUE about tertiary care?
- A. Provided by general practitioners
- B. Focuses on health promotion
- C. Highly specialized care
- D. All of the above
Correct Answer: C
Rationale: Tertiary care is highly specialized (C), per system e.g., surgery, rehab. Not by GPs (A), not promotion (B), not all (D) advanced focus. C truly defines tertiary's complexity, making it correct.
Which of the following statement best describes palliative care?
- A. Care given to terminally ill client
- B. Care that aims to relieve symptoms rather than cure
- C. Care that requires high technological skills
- D. Hospice care and Palliative care is the same
Correct Answer: B
Rationale: Palliative care relieves symptoms without curing (B), per WHO definition focusing on quality of life. It's for serious illness, not just terminal (A), doesn't need high tech (C), and differs from hospice (D) palliative spans broader stages. B best captures its symptom-focused essence, making it the correct description.
Which of the following statement best describe alternative therapy?
- A. Used with conventional medicine
- B. Replaces conventional medicine
- C. A diagnostic method
- D. A surgical approach
Correct Answer: B
Rationale: Alternative therapy replaces conventional medicine (B), per definition e.g., herbs over drugs. Not with (A), not diagnostic (C), not surgical (D) standalone. B best defines its substitute role, making it correct.
While giving a shift report on your assigned client, you realize that you forgot to record a nursing procedure done on your client. Which of the following methods of documentation would be best on your part?
- A. Write the procedure between the two lines of your shift documentation closest to the occurrence.
- B. Find a blank space in your earlier charting, and chart the procedure in that space.
- C. Tell the oncoming nurse to chart the procedure for you and to cite the time it was done.
- D. Chart the current date and time and 'Late entry,' indicating when and what was done.
Correct Answer: D
Rationale: A late entry with current date, time, and details of the missed procedure is best, maintaining accuracy and legality. Inserting between lines or blank spaces risks confusion, and delegating falsifies records. This method ensures transparency, critical for nursing accountability and care continuity.