Nokea
Yesterday, a male client had a transurethral resection of the prostate (TURP). Today, the client is concerned about the small amount of blood found in his urine. The nurse should explain to the client that the blood:
- A. should not be there on the second day.
- B. will stop when the Foley catheter is removed.
- C. is normal and he should not be concerned.
- D. can be removed by irrigating the bladder.
Correct Answer: C
Rationale: Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. The client will continue to have a small amount of hematuria even after the Foley catheter is removed. Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. Irrigating the bladder will not remove the hematuria. Irrigation is performed to remove blood clots and to facilitate urinary drainage.
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What is the rationale for administering oxygen in treating COPD?
- A. Relieve hypoxemia
- B. Increase carbon dioxide retention
- C. Increase intensity of respiratory drive
- D. Decrease respiratory secretions
Correct Answer: A
Rationale: Oxygen therapy alleviates hypoxemia, improving tissue perfusion.
For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to the nursing assistant?
- A. Assist the patient to identify patterns of fatigue.
- B. Recommend participation in a walking program.
- C. Report the amount and type of food consumed from the tray.
- D. Check the skin for redness and irritation after the treatment.
Correct Answer: C
Rationale: Monitoring food intake is a straightforward task suitable for a nursing assistant, while identifying fatigue patterns or recommending exercise requires more clinical expertise.
On assessing Mr. Puff, what would you expect to find?
- A. ‘Blue bloater’ appearance
- B. Copious amount of thin sputum
- C. Increased anteroposterior chest diameter
- D. Prolonged inspiratory time
Correct Answer: C
Rationale: The correct answer is C: Increased anteroposterior chest diameter. In patients with chronic obstructive pulmonary disease (COPD), like Mr. Puff, there is often air trapping leading to hyperinflation of the lungs. This results in an increased anteroposterior chest diameter, known as a "barrel chest" appearance. Option A (‘Blue bloater’ appearance) is associated with chronic bronchitis, not necessarily COPD. Option B (Copious amount of thin sputum) is more indicative of bronchiectasis. Option D (Prolonged inspiratory time) is a nonspecific finding and not typically associated with COPD.
Priority Decision: When the nurse asks a preoperative patient about allergies, the patient reports a history of seasonal environmental allergies and allergies to a variety of fruits. What should the nurse do next?
- A. Note this information in the patient's record as hay fever and food allergies.
- B. Place an allergy alert wristband that identifies the specific allergies on the patient.
- C. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents.
- D. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for allergies to anesthetics.
Correct Answer: C
Rationale: Understanding the nature and severity of allergies helps in planning appropriate perioperative care and avoiding potential allergens.
When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?
- A. Raise the affected extremity above the level of the heart.
- B. Immobilize the affected extremity with a splint
- C. Apply ice to the bite area
- D. Apply a tourniquet to the affected extremity.
Correct Answer: B
Rationale: The correct answer is B: Immobilize the affected extremity with a splint. This is important to prevent the spread of venom through the lymphatic system. Elevating the extremity (A) can increase the spread of venom. Applying ice (C) can constrict blood vessels, trapping venom in the area. Applying a tourniquet (D) can lead to tissue damage and worsen the condition. Immobilizing with a splint is the most effective way to limit movement and venom spread.