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The nurse is caring for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why he has Vectors are not supported in text mode. Please provide the text content you want to include, and I'll help format it appropriately. to have the CBI. Which of the following responses by the nurse is BEST?
- A. The CBI prevents urinary stasis and infection.
- B. The CBI dilutes the urine to prevent infection.
- C. The CBI enables urine to keep flowing.
- D. The CBI delivers medication to the bladder.
Correct Answer: C
Rationale: continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client
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Which assessment is most essential before administering digoxin to an adult?
- A. Ask the client if he has chest pain.
- B. Take an apical pulse.
- C. Take the client's blood pressure.
- D. Ask the client if he is short of breath.
Correct Answer: B
Rationale: Taking an apical pulse ensures the heart rate is above 60 bpm, as digoxin can cause bradycardia, a critical safety check.
The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client?
- A. Protection for the granulation tissue
- B. Heal infection
- C. Debride eschar
- D. Keep the tissue intact
Correct Answer: D
Rationale: Keep the tissue intact. Dry, intact eschar requires no intervention unless signs of infection appear.
A client admitted with a severe head injury following an MVA is placed on a ventilator, and hyperventilation is maintained. The primary reason for maintaining hyperventilation is:
- A. To increase oxygen to the brain
- B. To dilate the cerebral blood volume
- C. To increase the cerebral blood volume
- D. To promote cerebral vasoconstriction and decrease cerebral blood flow
Correct Answer: D
Rationale: Hyperventilation reduces $\mathrm{CO}_2$, causing cerebral vasoconstriction, which decreases cerebral blood flow and intracranial pressure in head injuries.
An adult who has multiple sclerosis is receiving cyclophosphamide (Cytoxan). The client asks the nurse why she is receiving the same drug her mother had when she had Hodgkin's disease. The nurse should include which information when responding?
- A. Multiple sclerosis is a type of cancer, so the same drugs are effective for both conditions.
- B. A side effect of cyclophosphamide (Cytoxan), a cancer drug, is immunosuppression. In multiple sclerosis, the immune system is attacking the client's nerves.
- C. Hodgkin's disease causes nervous system symptoms similar to those seen in multiple sclerosis.
- D. Multiple sclerosis and Hodgkin's disease are caused by the same organism, so the same drug is appropriate.
Correct Answer: B
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Which of the following electrolytes must be maintained in a steady state for a client receiving lithium?
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- B. Potassium
- C. Chloride
- D. Magnesium
Correct Answer: A
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