A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse to report to the provider?

Emesis of 100 mL

Oral temperature of 37.5" C (99.5° F)

Pain level of 4 on a 0 to 10 rating scale

Thick, red-colored urine

Answer and Explanation

The Correct Answer is D

a. Emesis of 100 mL: While emesis is a concern, the priority is to address potential complications related to the surgical procedure first.

b. Oral temperature of 37.5" C (99.5° F): This temperature is within a normal range, and it is not an immediate concern.

c. Pain level of 4 on a 0 to 10 rating scale: Pain is important to address, but the priority is to assess for potential complications such as bleeding or infection.

d. Thick, red-colored urine: This finding suggests the possibility of bleeding, which could be a complication of the TURP procedure. It is the priority finding to report to the provider for further evaluation.

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Correct Answer is D

Explanation

A. “I will notify my provider before taking any other medications.” - This statement reflects an understanding of the need to check for potential interactions with other medications, which is an appropriate response.

B. “I have made an appointment to see my dentist next week.” - Dental care is important, and

scheduling an appointment with the dentist is a responsible action. However, it does not indicate a misunderstanding about the medication.

C. “I will take this medication with meals.” - Taking phenytoin with meals is a correct instruction as it can help reduce gastrointestinal side effects.

D. "I'll be glad when my seizures stop so I can quit taking this medicine." - This statement

indicates a misunderstanding about the chronic nature of anti-seizure medications. The client needs further education on the importance of continuing the medication even if seizures stop.

A. “I will wait 10 min between each inhalation.” B. “I will hold my breath at least 10 seconds after inhaling the medication.” C. “I will tilt my head forward while inhaling the medication.” D. “I will hold the inhaler with my non-dominant hand.”

Correct Answer is B

Explanation

a. “I will wait 10 min between each inhalation.”: There is no need to wait 10 minutes between

inhalations of albuterol. The usual recommendation is to wait 1-2 minutes if a second inhalation is needed.

b. “I will hold my breath at least 10 seconds after inhaling the medication.”: Holding the breath for at least 10 seconds after inhaling helps ensure that the medication reaches the lower airways and is absorbed effectively.

c. “I will tilt my head forward while inhaling the medication.”: Tilted head position is not necessary for using an inhaler; a proper inhalation technique is more critical.

d. “I will hold the inhaler with my non-dominant hand.”: The hand used to hold the inhaler is not as crucial as proper inhalation technique, but using the dominant hand may be more comfortable for most individuals.

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A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

nurse is reinforcing teaching with a client who has a new prescription for phenytoin. The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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