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A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
- A. Output of dark amber urine
- B. Output of clear, light pink urine
- C. Output of bright red urine
- D. Output of burgundy colored urine
Correct Answer: D
Rationale: The correct answer is D: Output of burgundy colored urine. This indicates possible hemorrhage, a serious complication post-TURP. Dark amber urine (A) may suggest dehydration. Clear, light pink urine (B) is expected due to bladder irrigation post-TURP. Bright red urine (C) is common initially but should decrease over time. Burgundy colored urine (D) indicates active bleeding and requires immediate intervention.
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A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values?
- A. Creatinine
- B. Bilirubin
- C. Amylase
- D. Albumin
Correct Answer: C
Rationale: The correct answer is C: Amylase. In acute pancreatitis, there is inflammation of the pancreas leading to leakage of pancreatic enzymes like amylase into the blood. Elevated amylase levels are a hallmark of acute pancreatitis. Creatinine (A) is related to kidney function, bilirubin (B) to liver function, and albumin (D) to protein status. In acute pancreatitis, the focus is on pancreatic enzymes like amylase.
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?
- A. Pantoprazole 80 mg IV bolus twice daily
- B. Furosemide 40 mg IV
- C. Lactulose 20 mg PO
- D. Acetaminophen 650 mg PO
Correct Answer: A
Rationale: The correct answer is A: Pantoprazole 80 mg IV bolus twice daily. In acute pancreatitis, gastric acid hypersecretion can occur, leading to exacerbation of pancreatic inflammation. Pantoprazole is a proton pump inhibitor that helps reduce gastric acid secretion, which can alleviate pancreatic irritation. IV administration ensures rapid onset of action.
B: Furosemide is a diuretic used for conditions like heart failure or edema, not indicated for acute pancreatitis.
C: Lactulose is a laxative used for hepatic encephalopathy to reduce ammonia levels, not indicated for acute pancreatitis.
D: Acetaminophen is a pain reliever, but it does not address the underlying cause of acute pancreatitis.
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
- A. Establish the ability to communicate effectively.
- B. Increase mobility to a normal level.
- C. Promote independent living without assistance.
- D. Restore full visual function.
Correct Answer: A
Rationale: The correct answer is A: Establish the ability to communicate effectively. For a client who had a left hemispheric CVA, the left hemisphere is responsible for language and speech functions. Therefore, focusing on establishing effective communication is crucial in the rehabilitation program. It targets the specific deficits caused by the CVA and aims to improve the client's quality of life. Increasing mobility to a normal level (B) is important but may not be the priority in this case. Promoting independent living without assistance (C) is a broad goal that may encompass various aspects beyond communication. Restoring full visual function (D) is not directly related to a left hemispheric CVA.
A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?
- A. Changing the client's linens
- B. Administering oral medications
- C. Taking vital signs
- D. Completing a dressing change
Correct Answer: D
Rationale: The correct answer is D: Completing a dressing change. When completing a dressing change for a client who is HIV positive and postoperative, the nurse should wear a gown as personal protective equipment to prevent potential exposure to blood or body fluids. This is crucial for infection control and to protect both the nurse and the client.
Choice A: Changing the client's linens does not necessarily require wearing a gown unless there is a risk of exposure to blood or body fluids.
Choice B: Administering oral medications does not require wearing a gown as there is no risk of exposure to blood or body fluids.
Choice C: Taking vital signs also does not require wearing a gown unless there is a possibility of exposure to blood or body fluids during the procedure.
In summary, completing a dressing change involves the risk of exposure to blood or body fluids, hence the need for wearing a gown. Other actions listed do not carry the same level of risk, therefore do not require the use of a gown as personal protective
A nurse is assessing a client with menopausal symptoms considering hormone therapy. What is a contraindication?
- A. History of osteoporosis
- B. History of breast cancer
- C. History of anemia
- D. History of chronic migraines
Correct Answer: B
Rationale: The correct answer is B: History of breast cancer. Hormone therapy can potentially stimulate the growth of breast cancer cells. It is contraindicated in clients with a history of breast cancer due to the increased risk of cancer recurrence or progression. Other choices are incorrect because: A: History of osteoporosis is not a contraindication for hormone therapy, as it can actually help improve bone density. C: History of anemia is not a contraindication for hormone therapy. D: History of chronic migraines is not a contraindication, but it may need monitoring as hormone therapy can sometimes trigger migraines.