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A nurse is caring for a client who had a transurethral resection of the prostate and now is receiving continuous bladder irrigation. Which of the following actions should the nurse take? (Select all that apply.)

Document urine color

Monitor the client for reports of bladder spasms.

Check the drainage tubing for obstructions

Maintain the client in a left side-lying position

Use clean technique for intermitent irrigation

Answer and Explanation

Correct Answer : A,B,C

The correct answers are a. Document urine color, b. Monitor the client for reports of bladder spasms, and

c. Check the drainage tubing for obstructions.

a. Documenting urine color is important to monitor for any changes that may indicate complications or issues with the bladder irrigation. It helps identify any bleeding or clot formation.

b. Monitoring the client for reports of bladder spasms is crucial as bladder spasms can indicate irritation or obstruction in the urinary system. Prompt intervention can be provided to alleviate discomfort and prevent complications.

c. Checking the drainage tubing for obstructions is essential to ensure proper ﬂow of the bladder irrigation solution. Obstructions in the tubing can lead to inadequate irrigation, which can aﬀect the eﬀectiveness of the procedure and potentially lead to complications.

d. Maintaining the client in a left side-lying position is not specifically indicated for continuous bladder irrigation after a transurethral resection of the prostate. The client's position should be based on their comfort and overall condition, and there is no specific requirement for a left side-lying position in this context.

e. Using clean technique for intermitent irrigation is not appropriate for continuous bladder irrigation. Continuous bladder irrigation requires aseptic technique to reduce the risk of infection and contamination.

By performing these actions, the nurse ensures proper monitoring, documentation, and maintenance of the bladder irrigation system, promoting the client's safety and well-being.

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Correct Answer is B

Explanation

Answer: B. Elevated skin patches

Rationale:

A. Constipation:
Constipation is not a typical adverse effect of cefazolin. Antibiotics generally cause gastrointestinal symptoms like diarrhea rather than constipation, so this is not a primary concern with cefazolin therapy.

B. Elevated skin patches:
Elevated skin patches may indicate an allergic reaction, such as hives or a rash, which can be a serious side effect of cefazolin. Allergic reactions to antibiotics can escalate quickly and may require immediate medical attention. Monitoring for and reporting any skin changes is important to prevent potential complications.

C. Ringing in the ears:
Tinnitus (ringing in the ears) is not commonly associated with cefazolin. This symptom is more frequently associated with certain other antibiotics, such as aminoglycosides, but is not a primary concern with cefazolin use.

D. Depression:
Depression is not a known side effect of cefazolin. While mood changes may be seen with some medications, cefazolin’s primary side effects are related to hypersensitivity reactions and gastrointestinal symptoms.

A. Diplopia B. Tinnitus with ear pain C. Hyperreflexia D. Skin rash with fever

Correct Answer is D

Explanation

When taking allopurinol, a medication commonly used to treat gout and prevent kidney stones, the nurse should instruct the client to monitor and report the manifestation of a skin rash with fever. Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening condition that can occur as a rare side effect of allopurinol. It is characterized by a widespread rash, often with fever, and can progress to involve the mucous membranes (e.g., mouth, eyes) and cause severe complications.

The other manifestations mentioned, such as diplopia (double vision), tinnitus with ear pain, and hyperreflexia (exaggerated reflexes), are not typically associated with Stevens-Johnson syndrome and should not be directly attributed to this condition. However, it's important for the client to report any unusual or severe symptoms to their healthcare provider for further evaluation and appropriate management.

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A nurse is caring for a client who had a transurethral resection of the prostate and now is receiving continuous bladder irrigation. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin. For which of the following findings should the nurse instruct the adolescent to monitor and report to the provider?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

Correct Answer is D

Explanation

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