Nokea
The nurse is planning preoperative teaching with a client scheduled for a transurethral resection of the prostate (TURP). Which most frequent cause of postoperative pain should the nurse plan to include in the discussion?
- A. Bladder spasms
- B. Bleeding within the bladder
- C. Tension on the Foley catheter
- D. The lower abdominal incision
Correct Answer: A
Rationale: Bladder spasms can occur after this surgery because of postoperative bladder distention or irritation from the balloon on the indwelling urinary catheter. The nurse administers antispasmodic medications as prescribed to treat this type of pain. Options 2 and 3 are not frequent causes of pain. Some surgeons purposefully apply tension to the catheter for a few hours postoperatively to control bleeding. There is no incision with a TURP.
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A client takes isosorbide dinitrate (Isordil) as an antianginal medication. Which of the following statements indicates that the client understands the adverse effects of the drug?
- A. I should take my pulse before taking the medication.'
- B. I should take Isordil with food.'
- C. I will need to change positions slowly so I won't get dizzy.'
- D. It is important that I report any swelling in my ankles.'
Correct Answer: C
Rationale: Isosorbide dinitrate can cause orthostatic hypotension, so changing positions slowly prevents dizziness, indicating client understanding of adverse effects.
A usually reliable interpreter called by the nurse to help communicate with a mother of a child who does not speak English and has brought her child in for a routine visit has yet to arrive in the clinic. The nurse has paged the interpreter several times. Which of the following should the nurse do next?
- A. Continue with the examination.
- B. Reschedule the infant's appointment for later in the week.
- C. Ask the mother to stay longer in the hope that the interpreter arrives.
- D. Page the interpreter one more time.
Correct Answer: B
Rationale: Rescheduling ensures effective communication with the interpreter, avoiding potential misunderstandings during the visit.
When a client is prescribed seizure precautions, which interventions should the nurse include in the plan of care? Select all that apply.
- A. Having suction equipment readily available
- B. Keeping all the lights on in the room at night
- C. Keeping a padded tongue blade at the bedside
- D. Assisting the client to ambulate in the hallway
- E. Monitoring the client closely while showering
- F. Locking the client's bed in its lowest position
Correct Answer: A,D,E,F
Rationale: Suction equipment should be readily available to remove accumulated secretions after the seizure. The client should be accompanied during activities such as bathing and walking so that assistance is readily available and injury is minimized if a seizure begins. The bed is maintained in a low position for safety. A quiet, restful environment is provided as part of seizure precautions. This includes undisturbed times for sleep, while using a night-light (not all lights) for safety. A padded tongue blade is not kept at the bedside because nothing is inserted into the client's mouth during the seizure. Agency procedures regarding seizure precautions are always followed.
An expected physiologic response to a low potassium level is:
- A. Cardiac dysrhythmias.
- B. Hyperglycemia.
- C. Hypertension.
- D. Increased energy.
Correct Answer: A
Rationale: Hypokalemia can cause cardiac dysrhythmias due to its effect on cardiac muscle excitability, making it the most significant physiologic response.
Which is most closely aligned with ethics?
- A. Morals
- B. Laws
- C. Statutes
- D. Client rights
Correct Answer: A
Rationale: Ethics is most closely aligned with morals , as both involve principles of right and wrong that guide behavior, whereas laws and statutes are legal frameworks, and client rights are specific entitlements.