Question

1. A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

A. Notify the provider.

B. Check the tubing for kinks.

C. Adjust the rate of the bladder irrigant.

D. Irrigate the catheter.

2. A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?

1. Potassium 2.9 mEq/L
2. Phosphorous 4.5 mEq/L
3. Sodium 145 mEq/L
4. Calcium 8.2 mg/dL

3. A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?

1. A client who is scheduled for an abdominal x-ray and is awaiting transport
2. A client who has a prescription for discharge
3. A client who received oral pain medication 30 min ago

4. A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH   7.22 PaCO2 68 mm Hg PaO2 78 mm Hg Saturation    80%

1. Respiratory acidosis
2. Metabolic acidosis
3. Metabolic alkalosis
4. Respiratory alkalosis

1. A client who told an assistive personnel he is short of breath

Answer 1

1.

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Then the Nurse should Check the tubing for kinks.

Answer - B. Check the tubing for kinks.

Before doing anything, even before Notify the provider the nurse should first check the tubing for kinks because it is the common reason for the blockage of urinary catheters.

2.

A nurse is reviewing the laboratory results of a client who takes furosemide. Then Potassium 2.9 mEq/L should the nurse identify as the priority finding.

Answer - A. Potassium 2.9 mEq/L

Furosemide is a class of drug called loop diuretics which causes water loss as well as potassium loss from body. This patient has already a low potassium level(2.9 mEq/L), taking furosemide can further lowers the level which can lead to cardiac arrhythmias.

3.

A nurse is prioritizing client care after receiving change-of-shift report. Then the nurse should plan to see first A client who received oral pain medication 30 min ago to assess the effectiveness of the medication.

Answer - C. A client who received oral pain medication 30 min ago

4.

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the pH   7.22 PaCO2 68 mm Hg PaO2 78 mm Hg Saturation   80%.

Answer - A. Respiratory acidosis
pH lower than 7.35 (I.e 7.22) indicates Acidosis and This is due to High PaCO2 (I.e 68 mm Hg). (Here, the Main cause of High PaCO2 is Hypoventilation)