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 D

Explanation

A. Ask about pain. This is not the most important action because pain is not the primary problem in this situation. Pain may or may not be present, but it does not address the underlying cause of cyanosis.

B. Provide mouth care. This is not the most important action because mouth care does not improve oxygenation. Mouth care may be helpful to prevent infection and promote comfort, but it is not a priority in this case.

C. Offer fluids. This is not the most important action because fluids do not increase oxygen levels in the blood. Fluids may be beneficial to prevent dehydration and maintain circulation, but they are not urgent in this scenario.

D. Administer oxygen. This is the most important action because oxygen is essential for cellular function and survival. Oxygen therapy can reverse hypoxia and improve the client's condition.

A. Wrap him with a warm blanket. B. Give prescribed analgesic. C. Obtain blood glucose level. D. Burp the infant every two hours.

Correct Answer is B

Explanation

A. Wrapping the infant with a warm blanket might provide comfort but may not directly address the signs of discomfort or pain.
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 level 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 may relieve gas but does not address the symptoms of restlessness, grimacing, and drawing knees to the chest, which are indicative of pain or discomfort post-surgery.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) observes a client's mouth and lips as seen in the picture. Which follow-up action is most important for the PN to take?

Correct Answer is D

Explanation

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 client is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives on the unit to perform the procedure?

When a small fire breaks out in the kitchen of a long-term care facility, which task should be performed by the practical nurse (PN) rather than the unlicense assistive personnel (UAP)?

A female client is scheduled to begin chemotherapy for breast cancer. She tells the practical nurse (PN) that the healthcare provider explained that her hair is likely to fall out as a result of the treatment. The client asks the PN if her hair will grow back. Which response is best for the

A 2-day-old infant with hydrocephalus returns from surgery following placement of a ventriculoperitoneal shunt. Which nursing intervention(s) should the practical nurse (PN) implement during postoperative care? (Select all that apply.)

A child diagnosed with strep throat 3 days ago enters the clinic crying hysterically. The parent tells the practical nurse (PN) that the child screams in pain even with a light touch. The child is short of breath and anxious. Which manifestations warrant immediate intervention by the PN?

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.)