a nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate turp which of the following findings sho

ATI RN

ATI RN Exit Exam

1. A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?

A. Urine output of 30 mL/hr
B. Pink-tinged urine
C. Small blood clots in the urine
D. Blood pressure of 114/78 mm Hg

Correct answer: C

Rationale: The presence of small blood clots in the urine is an expected finding after a TURP due to the surgical manipulation of the prostate bed and the bladder. However, larger clots can indicate excessive bleeding and should be reported promptly. Urine output of 30 mL/hr is within the expected range for post-TURP clients, indicating adequate kidney perfusion. Pink-tinged urine is also normal after a TURP due to minor bleeding from the surgical site. A blood pressure of 114/78 mm Hg is within normal limits and does not require immediate reporting.

2. A nurse is preparing to administer a rectal suppository to a client. What action should the nurse take?

A. Encourage the client to hold their breath as long as possible.
B. Insert the suppository just past the anal sphincter.
C. Lubricate the suppository and insert it 1.5 cm (0.6 in) into the rectum.
D. Place the client in a Sims' position before inserting the suppository.

Correct answer: D

Rationale: The correct action the nurse should take when administering a rectal suppository is to place the client in a Sims' position. This position helps facilitate the proper administration of the suppository by allowing better access to the rectum. Encouraging the client to hold their breath as long as possible (Choice A) is unnecessary and not related to the administration of a rectal suppository. Inserting the suppository just past the anal sphincter (Choice B) is incorrect as it may not reach the rectum where it needs to be placed. Lubricating the suppository and inserting it 1.5 cm into the rectum (Choice C) is incorrect as the suppository needs to be inserted deeper into the rectum for proper absorption.

3. What is the initial intervention for a patient with chest pain?

A. Administer aspirin
B. Administer nitroglycerin
C. Provide pain relief
D. Prepare for surgery

Correct answer: A

Rationale: The correct initial intervention for a patient with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in case the chest pain is due to a cardiac event. Administering nitroglycerin may follow aspirin administration to help relieve chest pain by dilating blood vessels. Providing pain relief is a general approach and may not address the underlying cause of chest pain. Preparing for surgery would not be the initial intervention for chest pain unless there are specific indications for immediate surgical intervention.

4. How should bleeding in a patient on warfarin be monitored?

A. Monitor INR levels
B. Monitor hemoglobin levels
C. Monitor potassium levels
D. Monitor platelet count

Correct answer: A

Rationale: The correct answer is to monitor INR levels. INR levels are the most critical indicator for monitoring bleeding risk in patients on warfarin. INR stands for International Normalized Ratio and specifically measures the clotting tendency of the blood. Monitoring hemoglobin levels, potassium levels, or platelet count are not as directly relevant to assessing bleeding risk in patients on warfarin.

5. Which lab value should be closely monitored for a patient receiving heparin therapy?

A. Monitor aPTT
B. Monitor INR
C. Monitor potassium levels
D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial to monitor when a patient is receiving heparin therapy. Heparin works by potentiating antithrombin III, leading to the inhibition of thrombin and factor Xa. Monitoring aPTT helps ensure the patient is within the therapeutic range for heparin, reducing the risk of bleeding complications. Monitoring INR (Choice B) is more relevant for patients on warfarin therapy. Monitoring potassium (Choice C) and sodium levels (Choice D) is important but not specific to heparin therapy.