A client arrives to 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?

Irrigating the catheter manually.

Monitoring catheter drainage.

Discontinuing infusing solution.

Decreasing the flow rate.

Answer and Explanation

The Correct Answer is B

A. Irrigating the catheter manually:
Manually irrigating the catheter without an order may disrupt the clotting process and increase the risk of bleeding. It is not a routine nursing intervention post-TURP without specific orders.

B. Monitoring catheter drainage.
It is not within the nurse's scope of practice to manually irrigate the catheter without a healthcare provider's order, especially in the context of post-TURP care. The dark, pink-tinged outflow with blood clots indicates some expected bleeding following the procedure. The nurse should closely monitor the catheter drainage for the amount, color, and presence of clots.

C. Discontinuing infusing solution:
Discontinuing the normal saline irrigation may lead to clot formation and obstruction, potentially worsening the situation. The continuous bladder irrigation is often used to prevent clot formation and maintain catheter patency post-TURP.

D. Decreasing the flow rate:
The flow rate is typically set by the healthcare provider to maintain catheter patency and prevent clot formation. Decreasing the flow rate without specific orders may not be appropriate in this situation.

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Correct Answer is D

Explanation

A. Blood pH level:
The blood pH level is important for assessing the acid-base balance in the body. However, in the context of purulent drainage from a wound, it is not the primary laboratory value to review for signs of infection.

B. Platelet count:
Platelet count is important for assessing blood clotting ability. While it is a valuable parameter in overall care, it may not be directly related to the observation of purulent drainage from a wound, which typically suggests infection rather than a clotting issue.

C. Hematocrit:
Hematocrit measures the proportion of blood that is cellular. Like platelet count, it is important for assessing overall blood composition and oxygen-carrying capacity. However, it may not be the first parameter to review when evaluating signs of infection.

D. White blood cell (WBC) count:
The WBC count is a crucial parameter when assessing for infection. An elevated WBC count is a common response to infection as the body mobilizes its immune defenses. Reviewing the WBC count is particularly relevant when purulent drainage is observed, as it may indicate an inflammatory response to infection.

A. Carcinogens are substances that contain cancerous cells. B. Substances that change a cell so that it becomes cancerous are potential sources of cancer. C. Environmental factors such as sunlight and chemicals can cause cancer to spread. D. Carcinogens are in the environment and cannot be avoided.

Correct Answer is B

Explanation

A. Carcinogens are substances that contain cancerous cells:
This statement is incorrect. Carcinogens are substances that have the potential to cause cancer, but they do not necessarily contain cancerous cells themselves.

B. Substances that change a cell so that it becomes cancerous are potential sources of cancer:
This is the correct answer. Carcinogens are agents that can induce changes in the genetic material of cells, leading to the development of cancer. They can initiate or promote the process of carcinogenesis.

C. Environmental factors such as sunlight and chemicals can cause cancer to spread:
This statement is not accurate. Carcinogens can contribute to the initiation or promotion of cancer, but the spread of cancer (metastasis) involves complex biological processes and is not directly caused by environmental factors.

D. Carcinogens are in the environment and cannot be avoided:
This statement is not accurate. While carcinogens may be present in the environment, efforts can be made to minimize exposure and adopt preventive measures. Avoidance of known carcinogens and the promotion of a healthy lifestyle can contribute to cancer prevention.

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Naxlex Comprehensive Predictor Exams

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Correct Answer is D

Explanation

The nurse has conducted a cancer prevention community education program. In evaluating the participants understanding of the carcinogens, which statement indicates an accurate understanding?

Correct Answer is B

Explanation

Which information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)?

When providing care for an unconscious client who has seizures, which nursing intervention is most essential?

A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first?

An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement?

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next?

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?