Nokea
Which nursing intervention is most important before attempting to catheterize a client?
- A. Determine the client’s history of catheter use.
- B. Evaluate the level of anxiety of the client.
- C. Verify the client is not allergic to latex.
- D. Assess the client’s sensation level and ability to void.
Correct Answer: C
Rationale: Verifying latex allergy prevents allergic reactions during catheterization, as many catheters are latex-based. Catheter history, anxiety, and sensation/voiding ability are important but secondary to safety.
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As the nurse instructs the client about CBI, which information should the nurse provide? Select all that apply.
- A. You may feel the urge to urinate even though the bladder is empty.
- B. Do not to try to urinate around the catheter, because this will cause bladder spasms.
- C. You need to limit your fluids to 4 glasses per day.
- D. It is normal for the urine to be bloody immediately after surgery.
- E. The catheter will be removed in about a week.
- F. By the time you are ready to go home, your urine should be pink with a few clots.
Correct Answer: A,B,D,F
Rationale: These statements accurately describe CBI effects, expectations, and precautions post-TURP.
Postoperatively, which assessment finding is most suggestive that the client is hemorrhaging?
- A. Acute flank pain
- B. Abdominal distention
- C. Flushed, warm skin
- D. Nausea and vomiting
Correct Answer: B
Rationale: Abdominal distention may indicate internal bleeding, a critical sign of hemorrhage post-nephrectomy.
To avoid erroneous test results caused by the manipulation of the prostate, which diagnostic test should be performed before the client's rectal examination?
- A. Kidneys, ureters, bladder X-ray
- B. Needle biopsy of the prostate gland
- C. Prostate-specific antigen (PSA) test
- D. Transrectal ultrasound examination
Correct Answer: C
Rationale: The PSA test should be done before rectal examination, as manipulation can elevate PSA levels, leading to false results.
The client diagnosed with a urinary tract infection has a blood pressure of 83/56 mm Hg and a pulse of 122 bpm. Which should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Hang the IVPB antibiotic at the prescribed rate.
- C. Check the laboratory work to determine if the urine culture has been completed.
- D. Increase the normal saline IV fluids from keep open to 150 mL/hour on the IV pump.
Correct Answer: D
Rationale: Hypotension (83/56) and tachycardia (122 bpm) suggest septic shock from the UTI. Increasing IV fluids to 150 mL/hour improves perfusion, stabilizing the client. Notification, antibiotics, and lab checks are secondary to immediate fluid resuscitation.
Which information regarding the care of a cutaneous ileal conduit should the nurse discuss with the client?
- A. Teach the client to instill a few drops of vinegar into the pouch.
- B. Tell the client the stoma should be slightly dusky colored.
- C. Inform the client large clumps of mucus are expected.
- D. Tell the client it is normal for the urine to be pink or red in color.
Correct Answer: C
Rationale: Mucus in the urine is expected with an ileal conduit due to intestinal mucosa in the conduit. Vinegar instillation is not standard, a dusky stoma indicates ischemia, and pink/red urine suggests bleeding, which is abnormal.