Nokea
The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one (1) day postoperative TURP. Which intervention should the nurse implement?
- A. Remove the indwelling catheter.
- B. Titrate the NS irrigation to run faster.
- C. Administer protamine sulfate IVP.
- D. Administer vitamin K slowly.
Correct Answer: B
Rationale: Red urine and clots indicate bleeding. Increasing the irrigation rate clears clots and prevents catheter obstruction. Removing the catheter is premature, and protamine/vitamin K are for anticoagulant reversal, not surgical bleeding.
You may also like to solve these questions
When the client with an ileal conduit expresses concern about odor, which recommendation by the nurse is most effective?
- A. Place an aspirin tablet in the pouch.
- B. Use a deodorizing pouch spray.
- C. Change the pouch daily.
- D. Avoid acidic foods.
Correct Answer: B
Rationale: Using a deodorizing pouch spray effectively controls odor, addressing the client's concern.
Which statement indicates discharge teaching has been effective for the client who is postoperative TURP?
- A. I will call the surgeon if I experience any difficulty urinating.'
- B. I will take my Proscar daily, the same as before my surgery.'
- C. I will continue restricting my oral fluid intake.'
- D. I will take my pain medication routinely even if I do not hurt.'
Correct Answer: A
Rationale: Difficulty urinating post-TURP may indicate obstruction or complications, requiring prompt reporting. Proscar is typically discontinued post-TURP, fluid restriction is unnecessary, and routine pain meds are not advised.
The client is admitted to the emergency department after a gunshot wound to the abdomen. Which nursing intervention should the nurse implement first to prevent ARF?
- A. Administer normal saline IV.
- B. Take vital signs.
- C. Place client on telemetry.
- D. Assess abdominal dressing.
Correct Answer: A
Rationale: A gunshot wound can cause hypovolemia, leading to prerenal ARF. Administering normal saline IV restores volume and perfusion, preventing ARF. Vital signs, telemetry, and dressing assessment are important but secondary to fluid resuscitation.
Which of the following findings is the most significant information to report when caring for a client undergoing peritoneal dialysis?
- A. Loss of body weight
- B. Decreased serum creatinine
- C. Elevated body temperature
- D. Output that exceeds intake
Correct Answer: C
Rationale: An elevated body temperature may indicate infection, a serious complication of peritoneal dialysis, and must be reported.
Which statements made by the client's spouse most closely correlate with the diagnosis of acute glomerulonephritis? Select all that apply.
- A. My spouse's face looks rather puffy lately.
- B. Recently my spouse has been quite forgetful.
- C. My spouse has been salting food heavily.
- D. My spouse has been eating very well.
- E. My spouse hasn't been eating very well.
- F. My spouse gets up at night to use the bathroom.
Correct Answer: A,F
Rationale: Facial puffiness and nocturia are symptoms of glomerulonephritis, reflecting fluid retention and impaired kidney function.