Nokea
The nurse is caring for a client who has returned from the postanesthesia care unit after prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation (CBI). Which color description of the urinary drainage should lead the nurse to determine that the flow rate is adequate?
- A. Dark cherry
- B. Clear as water
- C. Pale yellow or slightly pink
- D. Concentrated yellow with small clots
Correct Answer: C
Rationale: The infusion of bladder irrigant is not at a preset rate; rather, it is increased or decreased to maintain urine that is a clear, pale yellow color or has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored or if clots are seen. Alternatively, the rate can be slowed down slightly if the returns are as clear as water.
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The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving?
- A. Flaccidity
- B. Presence of a gag reflex
- C. Positive Babinski's reflex
- D. Development of hyperreflexia
- E. Return of the bulbocavernous reflex
- F. Return of reflex emptying of the bladder
Correct Answer: C,D,E,F
Rationale: Spinal shock is associated with acute injury to the spinal cord with temporary suppression of reflexes controlled by segments below the level of injury. It may last for 1 to 6 weeks. Indications that spinal shock is resolving include return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder. The return of the bulbocavernous reflex in male clients is also an early indicator of recovery from spinal shock. Babinski's reflex (dorsiflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex. The gag reflex is not lost in spinal shock; therefore, its presence is not an indication of resolving spinal shock.
The nurse is monitoring the nutritional status of a client who is receiving enteral nutrition. Which should the nurse monitor as the best clinical indicator of the client's nutritional status?
- A. Daily weight
- B. Calorie count
- C. Skinfold measurement
- D. Serum prealbumin level
Correct Answer: D
Rationale: A serum prealbumin level is the most important parameter for determining the effectiveness of a client's nutritional management and nutritional status. Because prealbumin is a major plasma protein with a short half-life, it is sensitive to changes in protein synthesis and catabolism, and it is thus the best clinical indicator of nutritional status. It is a better nutritional index than a daily weight because body weight can be skewed quickly by changes in total body fluid. It is also a better index than anthropomorphic measurements because nutritional status is not necessarily related to skinfold thickness. The calorie count reports the total calories provided to the client without data regarding the client's use of the calories and nutrients.
A home care nurse is assigned to visit a preschooler who has a diagnosis of scarlet fever and is on bed rest. What data obtained by the nurse would indicate that the child is coping with the illness and bed rest?
- A. The child insists that his mother stay in the room.
- B. The child is coloring and drawing pictures in a notebook.
- C. The mother keeps providing new activities for the child to do.
- D. The child sucks his thumb whenever he does not get what he asked for.
Correct Answer: B
Rationale: According to Jean Piaget, for the preschooler, play is the best way for children to understand and adjust to life's experiences. They are able to use pencils and crayons, and they can draw stick figures and other rudimentary things. A child with scarlet fever needs quiet play, and drawing will provide that. Based on this information, none of the remaining options address positive coping mechanisms.
The nurse has provided discharge instructions to the parent of a child who has undergone heart surgery. Which statement by the parent would indicate the need for further instruction?
- A. My child can return to school for full days 2 weeks after discharge.
- B. I should allow my child to play inside but omit outside play at this time.
- C. I should have my child avoid crowds and people for 2 weeks after discharge.
- D. I should call the primary health care provider if my child develops faster or harder breathing than normal.
Correct Answer: A
Rationale: The child may return to school the third week after hospital discharge, but he or she should go to school for half days for the first week. Outside play should be omitted for several weeks, with inside play allowed as tolerated. The child should avoid crowds of people for 2 weeks after discharge, including crowds at day care centers and churches. If any difficulty with breathing occurs, the parent should notify the primary health care provider.
A client has been taking nadolol for the past month. Which finding would indicate a therapeutic effect of the medication?
- A. The client is afebrile.
- B. The client has clear breath sounds.
- C. The client reports no episodes of headache.
- D. The client has a blood pressure of 118 / 72mmHg .
Correct Answer: D
Rationale: Nadolol is a beta-adrenergic blocking agent that is used to treat hypertension. Therefore, a blood pressure within the normal range would indicate an effective response to the medication. Based on this information the remaining options are unrelated to the action of this medication.