The nurse is providing education to a client who is returning home with an indwelling urinary catheter after having a transurethral resection of the prostate (TURP). Which statement made by the client demonstrates a need for the nurse to clarify the instructions?

Start pelvic floor exercises.

Report fever or chills.

Increase fluid intake to help with hydration.

Tape urinary catheter securely to the thigh.

Answer and Explanation

The Correct Answer is A

Choice A reason: Starting pelvic floor exercises might be beneficial in the long term for improving urinary control after TURP. However, immediately following the surgery and while the indwelling catheter is in place, it may not be the appropriate time to begin these exercises. The nurse should clarify when and how to start pelvic floor exercises.

Choice B reason: Reporting fever or chills is crucial because these symptoms could indicate an infection, which requires prompt medical attention. This statement reflects an understanding of important post-operative care instructions and does not need clarification.

Choice C reason: Increasing fluid intake to help with hydration is important for clients with a urinary catheter. Adequate hydration helps flush the urinary system and prevent complications such as urinary tract infections. This statement does not need clarification.

Choice D reason: Taping the urinary catheter securely to the thigh helps prevent tension on the catheter and reduces the risk of accidental dislodgement or trauma. This instruction is correct and does not need clarification.

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Correct Answer is B

Explanation

Choice A reason: Assessing peripheral pulses is important for understanding the client's overall circulatory status, but it is not the most urgent assessment in this situation. The client's symptoms suggest a possible thyrotoxic crisis, which requires immediate evaluation of critical vital signs.

Choice B reason: Obtaining vital signs is the most important initial assessment. The client's report of anxiety, heart racing, and pounding could indicate a severe exacerbation of hyperthyroidism, potentially leading to a thyrotoxic crisis (thyroid storm). Vital signs will provide essential information on the client's heart rate, blood pressure, temperature, and overall stability, which are crucial for immediate management.

Choice C reason: The presence of a goitre can indicates thyroid gland enlargement, which is relevant for long-term management of hyperthyroidism. However, it does not provide immediate information on the client's current acute condition.

Choice D reason: Assessing emotional status is important for comprehensive care, but it is not the priority in this acute scenario. The client's physiological status needs to be stabilized first, as indicated by their vital signs, before focusing on their emotional state.

A. Degree of skin elasticity. B. Length of capillary refill. C. Rhythm of apical pulse. D. Volume of pedal pulses.

Correct Answer is C

Explanation

Choice A reason: The degree of skin elasticity is a measure often used to assess hydration status, especially in older adults. However, it does not provide direct information about the client's cardiac function or the cause of their current symptoms.

Choice B reason: The length of capillary refill is useful for assessing peripheral perfusion and overall circulatory status. While prolonged capillary refill can indicate poor perfusion, it does not provide specific information about heart rhythm or the cause of palpitations and faintness in a client with heart failure.

Choice C reason: The rhythm of the apical pulse is the most important assessment data to obtain in this scenario. The client's complaint of a fast-beating heart and feeling faint suggests a possible arrhythmia, which could be detected by assessing the rhythm of the apical pulse. This assessment can help identify irregular heartbeats, tachycardia, or other abnormalities that may require immediate intervention.

Choice D reason: The volume of pedal pulses can provide information about peripheral circulation, but it is not as crucial as assessing the heart rhythm in a client experiencing palpitations and faintness. Peripheral pulse volume may not change significantly with certain arrhythmias or cardiac issues that affect the central circulation more directly.

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The nurse is providing education to a client who is returning home with an indwelling urinary catheter after having a transurethral resection of the prostate (TURP). Which statement made by the client demonstrates a need for the nurse to clarify the instructions?

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Naxlex Comprehensive Predictor Exams

A client with hyperthyroidism tells the home health nurse, "I stopped taking my antithyroid medication and now I feel anxious. I can feel my heart racing and pounding." Which assessment is most important for the nurse to obtain?

Correct Answer is B

Explanation

A client with heart failure (HF) is waiting in the preoperative area for a scheduled procedure and tells the nurse, "My heart feels like it is beating too fast and I feel faint." After initiating a call for an electrocardiogram (ECG), which assessment data is most important for the nurse to obtain?

Correct Answer is C

Explanation

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