A client is receiving a postoperative continuous bladder irrigation via a three-way indwelling catheter for a transurethral resection of the prostate (TURP). Twelve hours after the surgery, the practical nurse (PN) is monitoring the urine in the catheter's bedside drainage unit and observes that the drainage is a thick red fluid with clots. What action should the PN implement?

Check for kinks in the drainage tubing.

Observe the drainage again in one hour.

Report the finding to the charge nurse.

Stop the irrigation solution immediately

Answer and Explanation

The Correct Answer is C

A.   Checking for kinks in the drainage tubing might be a part of troubleshooting, but the observed clots and thick red fluid require immediate attention, so informing the charge nurse is the priority.
B.   Delaying assessment for another hour could potentially exacerbate the issue if there's a problem with the irrigation or if the client's condition worsens.
C.   Reporting the finding to the charge nurse is crucial as it indicates potential complications such as bleeding or clot formation that need immediate intervention.
D.   Immediately stopping the irrigation solution without proper assessment and guidance could lead to complications and isn't the initial action warranted in this situation.

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Correct Answer is B

Explanation

A. Wrapping the infant with a warm blanket might provide comfort but may not directly address the cause of restlessness, grimacing, and drawing knees to the chest.
B. Giving the prescribed analgesic is essential to alleviate the infant's discomfort or pain following a surgical procedure like pylorotomy.
C. Obtaining blood glucose levels might be necessary in certain situations but does not directly address the observed signs of discomfort and pain in the infant.
D. Burping the infant every two hours is not the most appropriate action considering the presented symptoms. Administering the prescribed analgesic is more directly related to addressing the infant's discomfort.

A. Fresh cherries. B. Vanilla wafers. C. Cheddar cheese. D. Hard-boiled egg.

Correct Answer is C

Explanation

A. Fresh cherries are not typically high in tyramine and are usually considered safe for individuals trying to reduce tyramine intake.
B. Vanilla wafers generally do not contain significant amounts of tyramine and are often considered safe for those aiming to reduce tyramine intake.
C. Cheddar cheese is high in tyramine and should be avoided by individuals attempting to decrease their intake of tyramine-containing foods to manage migraines.
D. Hard-boiled eggs are not high in tyramine and are typically safe for consumption in individuals trying to reduce tyramine intake.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is caring for a 3-month-old male infant two days after a pylorotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement?

Correct Answer is B

Explanation

A female client who has migraine headaches wants to decrease her intake of foods high in tyramine to see if that will reduce the occurrence of headaches. Which snack choice should the practical nurse recommend that she eliminate from her diet?

Correct Answer is C

Explanation

The practical nurse (PN) overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. What is the best nursing action?

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?

What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

A female client with immune thrombocytopenic purpura (ITP) is transferred to a long-term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

During a clinic visit, the practical nurse (PN) observes an infant sucking on a pacifier that is made from a bottle nipple and stuffed with cotton. What should the PM do?

During a daily assessment in the nursery, the practical nurse (PN) notices three large bluishblack areas on the back and buttocks of an African-American infant. Which action should the PN take?

The practical nurse (PN) observes a client's initial postoperative dressing and drain as seen in the picture. Which follow-up actions should the PN implement? (Select all that apply.)