A client is receiving postoperative continuous bladder irrigation via a three-way indwelling catheter for a transurethral resection of the prostate (TURP). Twelve hours after the surgery, the practical nurse (PN) is monitoring the urine in the catheter's bedside drainage unit and observes that the drainage is a thick red fluid with clots. What action should the PN implement?

Check for kinks in the drainage tubing.

Report the finding to the charge nurse.

Stop the irrigation solution immediately.

Observe the drainage again in one hour.

Answer and Explanation

The Correct Answer is B

The correct answer is Choice B. Report the finding to the charge nurse. Choice A rationale:

Checking for kinks in the drainage tubing is an important troubleshooting step if there is a sudden decrease or absence of urine output. However, in this case, the PN's concern is the presence of thick red fluid with clots in the urine drainage. This finding indicates potential bleeding, which requires immediate attention and reporting.

Choice B rationale:

Reporting the finding to the charge nurse is the correct action. The presence of thick red fluid with clots in the urine suggests significant bleeding after the transurethral resection of the prostate (TURP) surgery. It is crucial to inform the charge nurse or the healthcare provider promptly so that appropriate interventions can be initiated to address the bleeding.

Choice C rationale:

Stopping the irrigation solution immediately may not be within the PN's scope of practice unless explicitly instructed by the healthcare provider. Moreover, abruptly stopping the irrigation may lead to complications, and it is essential to involve the charge nurse or healthcare provider in making this decision.

Choice D rationale:

Observing the drainage again in one hour is not appropriate in this situation. The presence of thick red fluid with clots in the urine drainage is an urgent concern that requires immediate action, not a wait-and-see approach.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answer is B. Extend the leg and flex the foot.

Choice A rationale:

Massaging the calf and foot is not recommended as it could potentially dislodge a blood clot if one is present, which can be dangerous.

Choice B rationale:

Extending the leg and flexing the foot helps to relieve the cramp by stretching the muscles involved. This is a safe and effective method to alleviate muscle cramps.

Choice C rationale:

Checking the pedal pulse in the affected leg is important for assessing circulation but does not directly address the immediate discomfort of the cramp.

Choice D rationale:

Elevating the leg above the heart is generally used to reduce swelling and improve circulation but is not specifically effective for relieving muscle cramps.

: 3

A. A client with diabetes mellitus (DM) develops cellulitis around a foot wound. B. Following suture removal from a client's stab wound, the wound dehisces. C. Following abdominal surgery, a client experiences wound evisceration. D. A client with a stage 4 sacral pressure ulcer develops purulent drainage.

Correct Answer is C

Explanation

The correct answer is Choice C. Following abdominal surgery, a client experiences wound evisceration.

Choice A rationale:

Cellulitis developing around a foot wound in a client with diabetes mellitus (DM) is a concerning situation, but it does not require the most immediate intervention compared to wound evisceration. Cellulitis is a bacterial skin infection that can usually be treated with antibiotics, while wound evisceration is a surgical emergency.

Choice B rationale:

Following suture removal from a stab wound, wound dehiscence is a serious complication, but it is not as immediately life-threatening as wound evisceration. Wound dehiscence is the separation of the wound edges after closure, and while it requires prompt attention, it does not involve the protrusion of organs from the wound.

Choice C rationale:

Wound evisceration, the protrusion of organs through a surgical incision, is a life-threatening complication that requires immediate intervention. The practical nurse should cover the exposed organs with a sterile, moist dressing and seek immediate medical assistance to prevent infection and further complications.

Choice D rationale:

For a client with a stage 4 sacral pressure ulcer developing purulent drainage is a concern, but it is not as immediately critical as wound evisceration. Proper wound care and infection management are essential, but the urgency level is lower compared to wound evisceration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the practical nurse (PN) implement?

Correct Answer is B

Explanation

When caring for postoperative clients, which situation requires the most immediate intervention by the practical nurse (PN)?

Correct Answer is C

Explanation

The practical nurse (PN) is caring for a child who was admitted after experiencing a generalized tonic-clonic seizure. When witnessing the child begin to seize again, which actions should the PN implement immediately? (Select all that apply.).

A client who had orthopedic surgery three days ago verbalizes difficulty in sleeping. Which initial intervention is best for the practical nurse (PN) to implement?

The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

Which finding should the practical nurse (PN) instruct the postpartum client to report to the charge nurse?

A client is admitted for treatment of Addison's crisis. Which finding is most important for the practical nurse (PN) to report to the charge nurse? Reference Range: Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L].

A client who had knee replacement surgery receives a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL prefilled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.).