Nokea
The nurse is caring for a client who had a transurethral resection of the prostate yesterday.
- A. What is the most concerning symptom in a client one day post-transurethral resection of the prostate?
- B. Urine output of 150 cc over 8 hours.
- C. Bladder spasms and urgency.
- D. Bright red urine with small clots.
- E. Burning on urination.
Correct Answer: A
Rationale: A urine output of 150 cc over 8 hours is critically low, indicating possible obstruction, bleeding, or renal impairment, requiring immediate intervention. Bladder spasms, bright red urine with clots, and burning are expected post-procedure but should be monitored.
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The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix) 40 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Glucose 100 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (3.0 mEq/L) from furosemide increases arrhythmia risk in heart failure. Options B, C, and D are normal.
A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
- A. Remove the unsightly markings with acetone or alcohol.
- B. Cover the radiation site with loose gauze dressing.
- C. Sprinkle baby powder over the radiated area.
- D. Refrain from using soap or lotion on the marked area.
Correct Answer: D
Rationale: Refraining from using soap or lotion preserves radiation site markings, ensuring accurate treatment. Removing markings, covering, or using powder risks disrupting the treatment field.
A client who had a total thyroidectomy this morning returns to the nursing care unit. How should the nurse position the client?
- A. Semi-sitting
- B. Supine
- C. Prone
- D. Sims'
Correct Answer: A
Rationale: Semi-sitting reduces neck swelling and promotes airway patency post-thyroidectomy. Supine, prone, or Sims' positions increase complications.
A client is admitted with acute abdominal pain. Which of the following findings would require immediate attention?
- A. BP 100/50, P 96, abdominal distention
- B. Temperature 99°, flatulence, nausea
- C. Urinary frequency and dysuria
- D. Temperature 99.2°, amber-colored urine
Correct Answer: A
Rationale: Hypotension (BP 100/50), tachycardia (P 96), and abdominal distention suggest a serious condition like internal bleeding or perforation, requiring immediate attention.
An 8-year-old boy falls off the swings at school and hits his head. He is examined by a physician at an urgent care center, diagnosed with a minor head injury, and sent home.
Which of the following statements, if made by the mother to the nurse, would require further teaching by the nurse?
- A. He should avoid blowing his nose or cleaning his ears for two days.'
- B. I should wake him every 3 hours tonight and tomorrow night to check him.'
- C. I can give him Tylenol every 4 hours if he complains of a headache.'
- D. He will be well enough to play in his soccer game tomorrow.'
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents increased pressure on area (2) should check level of consciousness and orientation every 3-4 hours (3) avoid use of sedatives, sleeping pills, alcohol with head injuries (4) correct-no strenuous activity for 48 hours