A client arrives at the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag.

Which action should the nurse take?

Decrease the flow rate.

Irrigate the catheter manually.

Discontinue infusing solution.

Monitor catheter drainage.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Decreasing the flow rate of the irrigation solution is not the best action in this situation. The presence of blood clots in the tubing and collection bag indicates that the client may be experiencing clot retention, which can lead to urinary obstruction. Decreasing the flow rate may not provide sufficient force to dislodge clots from the catheter, which could exacerbate the problem.
Choice B rationale
Manually irrigating the catheter is the most appropriate action when blood clots are observed in the tubing and collection bag. Clots can obstruct the catheter and disrupt the continuous bladder irrigation, leading to urinary retention and increased discomfort for the client. Manual irrigation can help dislodge and remove these clots, ensuring the patency of the catheter and the effectiveness of the irrigation.
Choice C rationale
Discontinuing the infusion of the irrigation solution is not the best action in this situation. The purpose of continuous bladder irrigation after a transurethral resection of the prostate is to prevent clot formation and retention by continuously flushing the bladder. Discontinuing the infusion could lead to the formation of more clots, potentially causing urinary obstruction.
Choice D rationale
While monitoring catheter drainage is an important part of postoperative care, it is not the most appropriate action in this situation. The presence of blood clots in the tubing and collection bag indicates a potential problem that requires immediate intervention. Simply monitoring the situation without taking action to resolve it could lead to urinary obstruction and increased discomfort for the client.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A rationale
Rubbing painful areas gently until the pain subsides is not typically recommended for managing pain in Raynaud’s disease. This could potentially cause more harm than good19.
Choice B rationale
Wearing gloves when handling cold items can help guard against painful spasms in Raynaud’s disease. Cold temperatures can trigger Raynaud’s attacks, so protecting the hands from cold is a key part of managing the condition19.
Choice C rationale
The need for return appointments for IV pain medication is not typically a primary component of pain management in Raynaud’s disease. Pain in Raynaud’s disease is usually managed through lifestyle modifications and medications19.
Choice D rationale
While enrolling in a pain clinic can provide pain relief alternatives, it’s not the first line of management for pain in Raynaud’s disease. The primary management strategies include avoiding cold exposure and using medications to improve blood flow19.

A. The patient should eat a diet high in protein and vitamins A and C. B. The patient should keep their legs elevated when sitting or lying down. C. The patient should maintain as much bed rest as possible. D. The patient should inspect their ankles daily for areas of darkening skin. E. The patient should apply intermittent cold compresses four times daily.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale
A diet high in protein and vitamins A and C can help promote wound healing. Protein is essential for tissue repair, and vitamins A and C play crucial roles in wound healing and immune function.
Choice B rationale
Keeping legs elevated when sitting or lying down can help reduce swelling and improve blood circulation, which is beneficial for healing venous leg ulcers.
Choice C rationale
Maintaining as much bed rest as possible is not typically recommended for patients with venous leg ulcers. Physical activity and movement can help improve blood circulation, which is beneficial for healing venous leg ulcers.
Choice D rationale
Inspecting ankles daily for areas of darkening skin can help detect early signs of worsening venous leg ulcers. Early detection and treatment can prevent complications and promote healing.
Choice E rationale
Applying intermittent cold compresses four times daily is not typically recommended for venous leg ulcers. Cold compresses can constrict blood vessels and reduce blood flow to the area, which may hinder the healing process.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who was recently diagnosed with Raynaud’s disease is concerned about pain management. Which nursing instruction should the nurse provide?

Correct Answer is B

Explanation

The nurse is providing discharge teaching to an older patient hospitalized for treatment of venous leg ulcers. What instructions should the nurse include in the teaching plan? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

An overweight young adult diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The patient reports feeling very weak and jittery. What actions should the nurse take? (Select all that apply)

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The nurse is teaching a patient with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During the patient’s return demonstration, the patient exhales using pursed lips. What should the nurse do next?

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication does the nurse anticipate being prescribed by the healthcare provider?

The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client’s plan of care?

A client receives a prescription for 1 liter of lactated Ringer’s intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?