A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. 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?

Irrigating the catheter manually.

Monitoring catheter drainage.

Discontinuing infusing solution.

Decreasing the flow rate.

Answer and Explanation

The Correct Answer is B

A. Irrigating the catheter manually:
Manually irrigating the catheter without an order may disrupt the clotting process and increase the risk of bleeding. It is not a routine nursing intervention post-TURP without specific orders.

B. Monitoring catheter drainage.
It is not within the nurse's scope of practice to manually irrigate the catheter without a healthcare provider's order, especially in the context of post-TURP care. The dark, pink-tinged outflow with blood clots indicates some expected bleeding following the procedure. The nurse should closely monitor the catheter drainage for the amount, color, and presence of clots.

C. Discontinuing infusing solution:
Discontinuing the normal saline irrigation may lead to clot formation and obstruction, potentially worsening the situation. The continuous bladder irrigation is often used to prevent clot formation and maintain catheter patency post-TURP.

D. Decreasing the flow rate:
The flow rate is typically set by the healthcare provider to maintain catheter patency and prevent clot formation. Decreasing the flow rate without specific orders may not be appropriate in this situation.

Nursing Test Bank

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Correct Answer is ["B","D"]

Explanation

A. Use standard precautions and wear a mask:
The use of standard precautions is appropriate for general care to prevent the transmission of infectious agents. However, specific to MRSA, additional precautions are needed. Wearing a mask is generally not necessary unless the client has respiratory symptoms that warrant respiratory precautions.

B. Institute contact precautions for staff and visitors:
This is a correct intervention. Contact precautions involve using gowns and gloves when providing care to prevent the transmission of MRSA. It is important for both healthcare staff and visitors to adhere to contact precautions to reduce the risk of spreading the infection.

C. Explain the purpose of a low bacteria diet:
The purpose of a low bacteria diet is generally unrelated to the management of MRSA. Low bacteria diets are often recommended for individuals with compromised immune systems to reduce the risk of foodborne infections. However, it may not be directly applicable to MRSA management.

D. Monitor the client's white blood cell count:
Monitoring the white blood cell count is a relevant intervention. An elevated white blood cell count may indicate an ongoing infection or an inflammatory response. Regular monitoring helps assess the client's immune response and the potential severity of the infection.

A. Initiate cardiac telemetry. B. Administer a PRN dose of a laxative. C. Implement seizure precautions D. Begin straining all urine

Correct Answer is D

Explanation

A. Initiate cardiac telemetry:
Cardiac telemetry is not the immediate priority in this case. Kidney stones are more likely to cause severe localized pain rather than cardiac-related symptoms.

B. Administer a PRN dose of a laxative:
Laxatives are not indicated for the management of kidney stones or the associated flank pain. The priority is to address the specific needs related to the possible passage of kidney stones.

C. Implement seizure precautions:
Seizure precautions are not relevant to the sudden onset of severe flank pain in the context of hyperparathyroidism. The focus should be on managing pain, assessing for kidney stone passage, and addressing the underlying cause.

D. Begin straining all urine.
Straining all urine allows for the collection and examination of any passed stones. This information is important for identifying the composition of the stones and guiding further management.

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Naxlex Comprehensive Predictor Exams

A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response?

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The nurse is performing the preoperative assessment for a client scheduled for a vertebroplasty of the cervical spine. Which finding should the nurse alert the healthcare provider of prior to the procedure?

The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi?