Nursing Elites

1. A client arrived to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?

• A. Monitoring catheter drainage
• B. Decreasing the flow rate
• C. Irrigating the catheter manually
• D. Discontinuing infusing the solution

Correct answer: C

Rationale: In this scenario, the nurse should choose option C - irrigating the catheter manually. This action can help clear the clots from the catheter and ensure proper bladder drainage. Monitoring catheter drainage (option A) alone may not address the issue of clots obstructing the flow. Decreasing the flow rate (option B) could potentially worsen clot formation. Discontinuing the infusing solution (option D) without addressing the clots first may lead to inadequate irrigation and increase the risk of complications.

2. A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should tell the client that:

• A. The test may be painful
• B. The test takes 2 to 3 hours
• C. Food and fluids are not allowed for 4 hours after the test
• D. Dye is injected and may cause a warm flushing sensation

Correct answer: D

Rationale: The correct answer is D. A contrast-aided CT scan involves the injection of dye to enhance the images obtained. The dye may cause a warm flushing sensation when injected, which is a common side effect. Choices A, B, and C are incorrect. CT with contrast is generally not a painful procedure, the duration of the test does not usually take 2 to 3 hours, and restrictions on food and fluids are typically before the test, not afterward.

3. A client with renal calculi is being assessed by a nurse. Which question should the nurse ask?

• A. Is there a family history of this problem?
• B. Do you consume cranberry juice?
• C. Do you urinate after sexual intercourse?
• D. Do you have burning sensation during urination?

Correct answer: A

Rationale: When assessing a client with renal calculi, it is important for the nurse to inquire about a family history of the problem. There is a genetic predisposition associated with renal stone formation, making it essential to assess if other family members have experienced renal stones. Choices B, C, and D are not directly related to renal calculi. Consuming cranberry juice is more relevant to urinary tract health, urinating after sexual intercourse is related to preventing urinary tract infections, and experiencing a burning sensation during urination is a symptom commonly associated with urinary tract infections, not renal calculi.

4. A patient has begun taking spironolactone (Aldactone) in addition to a thiazide diuretic. With the addition of the spironolactone, the nurse will counsel this patient to

• A. not take a potassium supplement daily.
• B. recognize that abdominal cramping is a common side effect.
• C. report decreased urine output to the provider.
• D. take these medications in the morning.

Correct answer: C

Rationale: When combining a potassium-sparing diuretic like spironolactone with a thiazide diuretic, there is an increased risk of hyperkalemia, especially in patients with poor renal function. Therefore, the patient should be educated to report any decrease in urine output, which could indicate a potential issue with kidney function. Choice A is incorrect because taking additional potassium supplements can further increase the risk of hyperkalemia. Choice B is incorrect as abdominal cramping is not a common side effect of spironolactone. Choice D is incorrect because the timing of medication administration is not directly related to the addition of spironolactone and thiazide diuretic; there is no specific recommendation to take these medications only at bedtime.

5. In a patient with chronic kidney disease, which of the following is a common electrolyte imbalance?

• A. Hyperkalemia.
• B. Hypokalemia.
• C. Hypernatremia.
• D. Hyponatremia.

Correct answer: A

Rationale: Hyperkalemia is a common electrolyte imbalance in chronic kidney disease. In chronic kidney disease, the kidneys' reduced function leads to the decreased excretion of potassium, resulting in elevated serum potassium levels. This can be dangerous as hyperkalemia can lead to life-threatening arrhythmias. Hypokalemia (Choice B) is less common in chronic kidney disease as the impaired kidneys tend to retain potassium. Hypernatremia (Choice C) is more commonly seen in conditions such as dehydration, not primarily in chronic kidney disease. Hyponatremia (Choice D) is also possible in chronic kidney disease but is less common compared to hyperkalemia.

Similar Questions