Nokea
The nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The nurse notes that the urine output is bright red with clots. Which of the following actions should the nurse take FIRST?
- A. Increase the irrigation flow rate.
- B. Notify the physician.
- C. Administer a diuretic as ordered.
- D. Stop the irrigation and assess the catheter.
Correct Answer: B
Rationale: bright red urine with clots indicates potential bleeding, requiring immediate physician notification
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The nurse is evaluating nutritional outcomes for a client with anorexia nervosa. Which one of the following is the most objective favorable outcome for the client?
- A. The client eats all the food on her tray
- B. The client requests that family bring special foods
- C. The client's weight has increased
- D. The client weighs herself each morning
Correct Answer: C
Rationale: Weight gain is the most objective and measurable outcome for anorexia nervosa, indicating improved nutritional status and progress toward recovery.
A client with otosderosis is scheduled for a stapedectomy. Which finding suggests a complication involving the seventh cranial nerve?
- A. Diminished hearing
- B. Sensation of fullness in the ear
- C. Inability to move the tongue side to side
- D. Changes in facial sensation
Correct Answer: D
Rationale: The seventh cranial (facial) nerve controls facial movements and sensation; changes in facial sensation post-stapedectomy suggest nerve involvement.
A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?
- A. You will be sitting for the examination procedure.
- B. Portions of the procedure will cause pain or discomfort.
- C. You will be asleep during the procedure.
- D. You will not be able to drink fluids for 24 hours following the study.
Correct Answer: B
Rationale: Renal biopsies may cause discomfort during needle insertion, and informing the client prepares them for the procedure.
The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
- A. Hallucinogenic drugs create both stimulant and depressant effects.
- B. Hallucinogenic drugs induce a state of altered perception.
- C. Hallucinogenic drugs produce severe respiratory depression.
- D. Hallucinogenic drugs induce rapid physical dependence.
Correct Answer: B
Rationale: Continuous observation is needed due to the altered perception caused by hallucinogens, which can lead to unsafe behaviors.
The physician has prescribed imipramine (ToFranil) for a client with depression. The nurse should continue to monitor the client's affect because the maximal effects of tricyclic antidepressant medication do not occur for:
- A. 48-72 hours
- B. 5-7 days
- C. 2-4 weeks
- D. 3-6 months
Correct Answer: C
Rationale: Tricyclic antidepressants like imipramine take 2-4 weeks to reach maximal therapeutic effect, requiring ongoing monitoring of the client's mood.