M/S Final

a nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. the nurse notes no urine output in the past 2 hr. which of the following actions should the nurse take first? a. check to determine if the catheter tubing is kinked b. palpate the bladder c. obtain a prescription to irrigate the catheter with NS d. encourage the client to drink more fluids

a. check to determine if the catheter tubing is kinked

a nurse is caring for a client who received spinal anesthesia 30 min ago. the client reports feeling dizzy, and the nurse notes that the client's bp is 84/54. which of the following actions should the nurse take? a. place the client in a head-down position b. assess the placement of the catheter c. prepare to administer an IV reversal agent d. assist the client in passive ROM movements

a. place the client in a head-down position

a nurse is providing discharge teaching to a client following an open radical prostatectomy. the client is going home with an indwelling urinary catheter. which of the following statements by the client indicates an understanding of the teaching? a. I will be able to take a tub bath in 1 week b. I will change the catheter drainage bag once each week c. I will use suppositories to prevent constipation d. I will regain my bladder control once the catheter is removed

b. I will change the catheter drainage bag once each week

a nurse is caring for a group of clients who have mobility issues. which of the following clients is at the greatest risk for complication? a. a 3 yo w/ a burned foot b. an 80 yo who has a hip fracture c. a 30 yo who has a cast applied for a fractured ankle d. a 42 yo who has an indwelling urinary catheter

b. an 80 yo who has a hip fracture

A nurse is caring for a client who has an indwelling urinary catheter. which of the following actions should the nurse take? a. place the drainage bag on the clients abdomen when transferring from a bed to cart b. empty the drainage bag when half-full of urine c. rest the drainage bag on the floor when closing the drainage spigot during emptying d. disconnect the drainage bag when obtaining a urine specimen

b. empty the drainage bag when half-full of urine

a nurse is caring for a client who is 2 days postop. which of the following findings indicates that the client is developing an infection? a. temperature 37.8 degrees C (100 F) b. erythema at the incision site c. WBC count 9000/mm^3 d. pain reported as 6 on a scale of 0 to 10

b. erythema at the incision site

a nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. which of the following pieces of information should the nurse include in the teaching? a. exhale slowly to reach the goal volume b. hold the breath for 5 seconds after goal volume is reached c. continue to breathe deeply between each cycle d. limit the repeat pattern of breathing to 5 breaths

b. hold the breath for 5 seconds after goal volume is reached

a nurse is assessing a client who is 12 hr postop following an open cholecystectomy. which of the following findings should the nurse report to the provider? a. hypoactive bowel sounds b. indwelling urinary catheter output of 25 mL/hr c. HR of 96/min d. serous drainage at the surgical incision site

b. indwelling urinary catheter output of 25 mL/hr

a nurse is preparing to insert an indwelling urinary catheter for a male client. which of the following locations should the nurse secure the urinary catheter tubing? a. lateral thigh b. lower abdomen c. mid-abdominal region d. medial thigh

b. lower abdomen

a nurse is planning to delegate the postoperative care of a client following an appendectomy. which of the following actions should the nurse assign to an AP? a. showing the client how to use the PCA pump b. recording UO after emptying the indwelling urinary catheter c. assisting the client out of bed and into a chair for the first time after surgery d. checking the client's abdominal wound dressing

b. recording UO after emptying the indwelling urinary catheter

a nurse is preparing a client who is scheduled for an IV pyelogram. which of the following findings should the nurse report to the provider? a. allergy to egg products b. vomiting and diarrhea for the last 6 hr c. serum potassium of 3.6 mEq/L d. serum creatinine of 1.2 mg/dL

b. vomiting and diarrhea for the last 6 hr

a nurse is caring for a client who is receiving peritoneal dialysis. the nurse notes that the client's dialysate output is less than the input and his abdomen is distended. which of the following actions should the nurse take? a. insert an indwelling urinary catheter b. administer pain medication to the client c. change the client's position d. place the drainage bag above the client's abdomen

c. change the client's position

a nurse is teaching a group of nurses about the effects of a client receiving spinal anesthesia. which of the following pieces of information should the nurse include in the teaching? a. lidocaine toxicity will cause the client to develop tachycardia. b. most clients develop a headache from spinal anesthesia c. hypotension is an adverse effect of spinal anesthesia d. urinary urgency occurs when the client has spinal anesthesia

c. hypotension is an adverse effect of spinal anesthesia

An AP is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? a. the AP uses soap and water to clean the perineal area. b. the AP tapes the catheter to the client's inner thigh c. the AP hangs the collection bag at the level of the bladder d. the aP ensures there are no kinks in the drainage tubing

c. the AP hangs the collection bag at the level of the bladder

a nurse is assessing the abdominal incision of a client who is 3 d postoperative. the incision is slightly edematous and pink with crusting on the edges and is draining serosanguineous fluid. which of the following assessments describes the incision? a. the incision is showing early signs of infection b. the incision is showing early signs of dehiscence c. the incision is showing signs of healing without complications d. the incision is showing signs of developing a fistula

c. the incision is showing signs of healing without complications

a nurse is providing education about continuous heparin therapy for a client who is 18 hr postpartum and has developed a DVT. which of the following statements should the nurse include in the teaching? a. an adverse effect of this medication is drowsiness b. this medication will require frequent monitoring of WBC levels c. use a soft toothbrush to brush your teeth gently d. avoid taking acetaminophen while receiving this medication

c. use a soft toothbrush to brush your teeth gently

a nurse is preparing to transfuse a unit of PRBCs for a client who has anemia. which of the following actions should the nurse take first? a. hang an IV infusion of NS w/ the blood b. compare the clients ID number w/ the number on the blood c. witness the informed consent document d. obtain pre transfusion vital signs

c. witness the informed consent document

a nurse is preparing to insert an indwelling urinary catheter for a female client. which of the following actions should the nurse have the client perform just before inserting the catheter? a. swallow water b. prepare for a painful sensation d. hold her breath d. bear down gently

d. bear down gently

a nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. the client has an indwelling urinary catheter in place. which of the following actions should the nurse take? a. withdraw the specimen from the drainage bag b. cleanse the collection port with soap and water c. place the specimen in a clean specimen cup d. clamp the tubing below the collection port

d. clamp the tubing below the collection port

a nurse is caring for a client who is 12 h postop following a total hip arthroplasty. which of the following medications should the nurse anticipate administering to this client to prevent DVT? a. aspirin b. warfarin c. ticagrelor d. enoxaparin

d. enoxaparin

a nurse is caring for a client who is postoperative following a laparotomy. the client has an indwelling urinary catheter and a Jackson-Pratt drain in place. which of the following findings indicates that the client is developing a postoperative complication? a. pain scale score 5/10 b. urine output of 65 mL/hr c. 20 mL of bright red drainage from the drain d. pulse ox 85%

d. pulse ox 85%

a nurse is assessing a client who is 4 hr postoperative following a TURP and has an indwelling urinary catheter in place. which of the following findings should the nurse expect? a. blood-tinged urine in the drainage bag b. catheter tubing coiled at the client's side c. client report of severe bladder spasms d. urinary output of 20 ml/hr

d. urinary output of 20 ml/hr