Nokea
The nurse notes dark red blood and a few clots in the catheter of a client two days after a transurethral prostatectomy (TURP). The nurse should first:
- A. Prepare the client for a return to surgery.
- B. Apply traction to the urethral catheter.
- C. Document the findings as normal.
- D. Decrease the client's oral fluid intake.
Correct Answer: B
Rationale: The appearance of dark red blood with a few clots indicates a venous bleed. Traction to the urethral catheter and increasing the client's fluid intake should be tried first before calling the doctor. Answer A would be indicated for the client with an arterial bleed, which is characterized by the appearance of bright red blood and many clots in the catheter, so it is incorrect.
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Two days after admission, a client's sputum culture is reported as positive for tuberculosis.
While awaiting orders from the physician, the nurse should
- A. initiate measures to transfer the client to a tuberculosis unit.
- B. institute measures to initiate airborne precautions.
- C. arrange for all of the client's personal effects to be decontaminated.
- D. notify the client's family that they have been exposed to a contagious disease.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) this action is unnecessary at this time, and if indicated, the physician will write appropriate transfer orders (2) correct-clients with tuberculosis are placed on airborne precautions in the hospital, and the nurse should begin preparations for this immediately (3) personal effects do not have to be decontaminated (4) it is the physician's job to tell the family when indicated
The nurse is caring for an older adult. Which statement made by the client is not typical of normal aging?
- A. I seem to be more sensitive to the taste of salt than I used to be.'
- B. I have trouble reading the newspaper.'
- C. I don't drive at dusk anymore.'
- D. Sometimes I have trouble matching my socks.'
Correct Answer: A
Rationale: Increased sensitivity to salt taste is not typical of aging; taste sensitivity usually decreases. Difficulty reading, avoiding dusk driving, and color matching issues are normal aging changes.
A 38-year-old woman, mother of two, has a mastectomy for breast cancer.
- A. Which client response one month after a mastectomy indicates a normal reaction to the surgery?
- B. I have been helping my family deal with their feelings about the surgery.'
- C. I have been having difficulty coping with the surgery and cry frequently.'
- D. I have been unable to leave the house or talk to my friends about the surgery.'
- E. I am doing just great since the surgery and have gone back to work at my job.'
Correct Answer: B
Rationale: Frequent crying and difficulty coping one month post-mastectomy reflect a normal grieving process for the loss of a body part. Helping family cope is premature, social withdrawal indicates abnormal adjustment, and immediate return to normal activities suggests denial, which is too early for integration.
A client is in the third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
- A. Counsel the woman to consent to HIV screening
- B. Perform tests for sexually transmitted diseases
- C. Discuss her high risk for cervical cancer
- D. Refer the client to a family planning clinic
Correct Answer: A
Rationale: Counsel the woman to consent to HIV screening. The client's behavior places her at high risk for HIV. Testing is the first step to ensure early treatment if positive.
The nurse is caring for a client receiving intravenous nitroglycerin for acute angina. What is the most important assessment during treatment?
- A. Heart rate
- B. Neurologic status
- C. Urine output
- D. Blood pressure
Correct Answer: D
Rationale: The vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable and then every 30 minutes to every hour.