Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

Lay prone for 24 hours after the procedure.

Report any allergies to shellfish or iodine.

Report any painful urination, blood in urine, or fever.

Avoid strenuous activity and sports for at least 2 weeks.

Answer and Explanation

The Correct Answer is C

Rationale

A. After a cystoscopy, clients typically do not need to lay prone (face down) for an extended period. They are usually allowed to resume normal activities fairly soon after the procedure.

B. This instruction is important because iodine-based contrast agents are commonly used during cystoscopy procedures to enhance visualization of the urinary tract. Clients with allergies to shellfish (due to potential cross-reactivity with iodine) or iodine itself should be identified to avoid allergic reactions. This allows the healthcare team to take appropriate precautions and possibly use alternative agents if needed.

C. This instruction is crucial for monitoring post-procedure complications. Painful urination, blood in urine (hematuria), and fever can indicate infection or other complications following a cystoscopy. Prompt reporting allows for early intervention and treatment if necessary.

D. This instruction is not typically necessary after a cystoscopy. Most clients can resume normal activities, including light exercise, shortly after the procedure. Avoiding strenuous activity for two weeks would be excessive and not aligned with typical post-cystoscopy recovery guidelines.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale

A. An elevated neutrophil count suggests an active immune response to infection, supporting the clinical findings of purulent drainage. This information is crucial for the healthcare provider to assess the severity of the infection and guide treatment.

B. Hematocrit changes are more related to blood volume, fluid shifts, or bleeding rather than infection. While it may be monitored postoperatively, it does not provide specific information about infection.

C. Platelet count is important for assessing clotting function but does not directly indicate infection or purulent drainage.

D. Serum sodium levels are part of electrolyte balance and hydration status monitoring but do not directly relate to the presence of infection.

A. Assess for symmetrical chest movement.<br> B. Auscultate for presence of bilateral breath sounds. C. Obtain a portable chest x-ray to verify ETT location. D. Monitor ETT markings between 22 and 26 cm at teeth line. E. Check for capillary refill of 3 seconds or less.

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

Explanation

Rationale

A. This involves visually inspecting the chest to ensure both sides rise and fall equally during ventilation. Symmetrical chest movement suggests that both lungs are being adequately ventilated.

B. Auscultation involves listening with a stethoscope over the chest to confirm the presence of breath sounds in both lung fields. Bilateral breath sounds indicate that the ETT is correctly positioned in the trachea, allowing air to reach both lungs.

C. A chest x-ray provides a definitive confirmation of the ETT placement in relation to the trachea and lungs. It allows visualization of the tube's position relative to anatomical landmarks, such as the carina, which helps ensure proper placement.

This involves checking the markings on the ETT tube to ensure it is inserted to the correct depth. Typically, the ETT should be positioned with its tip approximately 2 to 4 cm above the carina, which corresponds to the 22-26 cm mark at the teeth line in adults. However, it does not confirm correct placement.

E. Capillary refill is a measure of peripheral perfusion and is unrelated to ETT placement. It assesses circulatory status by pressing on a nail bed and observing the time it takes for color to return. It does not provide information about ETT placement.

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Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is A

Explanation

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

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

Explanation

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