A nurse is caring for a client who is 6 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse include in the plan of care? (Select all that apply.).

Encourage the client to try to void.

Secure the drainage tube to the client's thigh.

Monitor the client's urine output every 2 hr.

Administer antispasmodics for bladder spasms.

Perform intermittent bladder irrigation.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:
Is appropriate to assess postoperative urinary function after transurethral resection of the prostate (TURP). It helps monitor the return of normal bladder function.
Choice B rationale:
Is not necessary and could potentially cause discomfort and increased risk of tube dislodgment. Securing the tube properly to the bed or clothing is a more appropriate method.
Choice C rationale:
Is essential to assess urinary function, and fluid balance, and identify any potential complications such as urinary retention or excessive bleeding.
Choice D rationale:
Helps alleviate discomfort and prevent spasms after TURP. Bladder spasms can be common after the procedure, and antispasmodics can aid in managing them.
Choice E rationale:
Is necessary to keep the catheter patent and prevent clot formation in the urinary tract. It helps maintain proper drainage and prevents complications.

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Correct Answer is B

Explanation

Let's break down the calculation:

Given:

Patient weight: 154 lbs
Enoxaparin dosage: 0.75 mg/kg
Available enoxaparin: 60 mg/0.6 mL

Step 1: Convert pounds to kilograms:

1 lb is approximately 0.4536 kg
So, 154 lbs = 154 * 0.4536 kg/lb = 69.85 kg (approximately 70 kg)

Step 2: Calculate the total dose of enoxaparin:

Desired dose = 0.75 mg/kg * 70 kg = 52.5 mg

Step 3: Determine the volume to administer:

We have enoxaparin 60 mg/0.6 mL
To find the volume for 52.5 mg:
- (52.5 mg / 60 mg) * 0.6 mL = 0.525 mL
- Rounded to the nearest tenth, this is 0.5mL.

Therefore, the nurse should administer 0.5mL of enoxaparin

A. Elevated WBC Count. B. Elevated amylase level. C. Rebound tenderness. D. Ascites. E. Anorexia.

Correct Answer is ["A","C","E"]

Explanation

Choice A rationale:

An elevated white blood cell (WBC) count is an expected manifestation in a client with suspected appendicitis. Inflammation in the appendix leads to an immune response, causing an increase in WBC count.

Choice B rationale:

Elevated amylase level is not typically associated with appendicitis. Elevated amylase is more commonly seen in pancreatitis, not appendicitis.

Choice C rationale:

Rebound tenderness, which refers to increased pain when pressure is released rather than applied, is a classic symptom of appendicitis. The nurse should expect to find rebound tenderness during the abdominal assessment.

Choice D rationale:

Ascites are not a common manifestation of appendicitis. Ascites is the accumulation of fluid in the abdominal cavity and are more commonly seen in liver cirrhosis and certain other conditions, but not in appendicitis.

Choice E rationale:

Anorexia, or loss of appetite, can be seen in clients with appendicitis due to the inflammation and discomfort in the abdominal region.

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A nurse is caring for a client who is 6 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse include in the plan of care? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer?(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).

Correct Answer is B

Explanation

A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect?(Select all that apply.).

Correct Answer is ["A","C","E"]

Explanation

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