Nokea
A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hours ago. The nurse notes pink tinged urine and the drainage bag.
Which of the following actions should the nurse take?
- A. Maintain the irrigation solution rate.
- B. Increase the irrigation solution rate.
- C. Clamp the catheter for 30 minutes and reassess.
- D. Notify the provider immediately.
Correct Answer: A
Rationale: The correct answer is A: Maintain the irrigation solution rate. This is the appropriate action because maintaining the irrigation solution rate ensures continuous flushing of the catheter to prevent blockages and maintain patency. Increasing the rate could lead to complications like fluid overload. Clamping the catheter and reassessing can cause catheter obstruction. Notifying the provider immediately may not be necessary unless there are specific complications or concerns.
You may also like to solve these questions
A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode.
Which finding should the nurse expect?
- A. Move quickly from one idea to the next
- B. Feelings of hopelessness or worthlessness
- C. Decreased energy and fatigue
- D. Difficulty concentrating or making decisions
- E. Changes in appetite, either increased or decreased
Correct Answer: B
Rationale: The correct answer is B: Feelings of hopelessness or worthlessness. This is a key symptom of depression and is often present in individuals experiencing a depressive episode. It is important for the nurse to recognize this as it can indicate a serious mental health issue that requires intervention. Choices A, C, D, and E are also common symptoms of depression, but they are not as specific to the core of the condition as feelings of hopelessness or worthlessness. Moving quickly from one idea to the next (A) may suggest mania or hypomania rather than depression. Decreased energy and fatigue (C), difficulty concentrating or making decisions (D), and changes in appetite (E) are also common in depression, but they are not as indicative of the deep emotional distress associated with feelings of hopelessness or worthlessness.
A home health nurse is planning care for a client who has Alzheimer's disease.
Which of the following actions should the nurse include in the plan of care?
- A. Encourage physical activity prior to bedtime
- B. Replace the carpet with hardwood floors
- C. Wear clothing with zippers instead of buttons
- D. Place locks at the top of exterior doors
Correct Answer: D
Rationale: The correct answer is D: Place locks at the top of exterior doors. This action is crucial in ensuring the safety and security of the individual, especially in cases where the person may be at risk of wandering or elopement. Placing locks at the top of exterior doors can prevent the individual from leaving the house unsupervised, which is essential for their safety. Encouraging physical activity prior to bedtime (A) may disrupt sleep patterns. Replacing carpet with hardwood floors (B) is not directly related to the safety of the individual. Wearing clothing with zippers instead of buttons (C) may be a personal preference but does not address safety concerns.
A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu.
The nurse should recognize which of the following findings as a potential contraindication for using lavender?
- A. The client has a history of asthma
- B. The client takes furosemide twice daily
- C. The client has a history of alcohol use disorder
- D. The client takes vitamin C daily
Correct Answer: A
Rationale: The correct answer is A: The client has a history of asthma. Lavender can trigger asthma symptoms due to its volatile organic compounds. People with asthma may experience worsened symptoms or even asthma attacks when exposed to lavender. Asthma is a contraindication as it can lead to serious health complications.
Explanation for other choices:
B: The client takes furosemide twice daily - Furosemide is a diuretic and does not interact significantly with lavender.
C: The client has a history of alcohol use disorder - Alcohol use disorder does not directly contraindicate the use of lavender.
D: The client takes vitamin C daily - Vitamin C does not interact significantly with lavender.
A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea.
Which action should the nurse include in the plan?
- A. Offer the client three large meals each day
- B. Provide small, frequent meals to reduce fatigue and improve intake.
- C. Encourage the client to drink fluids immediately before or after meals to prevent early satiety.
- D. Offer high-calorie, nutrient-dense foods to support weight maintenance.
- E. Monitor the client's weight regularly to assess nutritional status.
Correct Answer: B
Rationale: The correct answer is B: Provide small, frequent meals to reduce fatigue and improve intake. This option is the most appropriate because small, frequent meals can help prevent fatigue and improve nutrient intake by ensuring a steady supply of energy throughout the day. Offering three large meals (option A) may overwhelm the client and lead to fatigue. Encouraging fluid intake before or after meals (option C) may cause early satiety and reduce food intake. Offering high-calorie, nutrient-dense foods (option D) can be beneficial, but the frequency of meals is more crucial in this scenario. Monitoring weight (option E) is important but does not directly address the issue of fatigue and intake.
A school nurse is performing scoliosis screening.
The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?
- A. Uneven shoulder and pelvic heights
- B. Symmetrical scapulae
- C. Equal leg lengths
- D. Straight spinal alignment
Correct Answer: A
Rationale: The correct answer is A. Uneven shoulder and pelvic heights are indicative of scoliosis due to the lateral curvature of the spine. Symmetrical scapulae, equal leg lengths, and straight spinal alignment are not typical signs of scoliosis. Symmetrical scapulae and equal leg lengths suggest normal alignment, while straight spinal alignment does not reflect the characteristic curvature seen in scoliosis cases. Therefore, identifying uneven shoulder and pelvic heights is crucial in recognizing scoliosis.