You arrive for your 7 a.m. shift on the urology unit and the night nurse gives a report on the following patients who will be under your care. Which one would you see first?
Mr. Dominic, newly admitted for evaluation of bladder cancer.
Mr. Bradford is 3 days post-radical prostatectomy for invasive bladder cancer. His urine output overnight was 1200 mL of blood-tinged urine. He did not sleep well and ambulated twice overnight complaining of gas pains.
Mr. Jennings had a TURBT (transurethral resection of bladder tumor) yesterday. He is complaining of bladder spasms. He had 3000 mL of bladder irrigation in overnight and 2950 mL out.
Ms. Griffiths, who had a cystectomy for bladder cancer 3 years ago, was admitted via the ER overnight with a complaint of severe hip pain and anorexia. Her lab tests were normal with the exception of elevated liver enzymes. After an initial dose of Dilaudid 1 mg, she reports her pain as 2 on a 0 to 10 scale and has slept fitfully overnight.
The Correct Answer is B
Choice A reason: Mr. Dominic's evaluation for bladder cancer is important, but there are no acute symptoms reported that require immediate attention over the other patients listed.
Choice B reason: Mr. Bradford's condition is the most concerning. He is 3 days post-radical prostatectomy with significant blood-tinged urine output and complaints of gas pains, which could indicate complications such as bleeding or infection that need immediate assessment.
Choice C reason: Mr. Jennings’ condition is stable with an almost equal in-and-out bladder irrigation, though bladder spasms should be addressed, it is not as immediately critical as Mr. Bradford's symptoms.
Choice D reason: Ms. Griffiths is stable with managed pain levels and normal lab results except for elevated liver enzymes, which do not present an immediate threat compared to Mr. Bradford's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Spironolactone is a potassium-sparing diuretic, so it is more likely to cause elevated potassium levels rather than decreased levels.
Choice B reason: Chloride levels are not typically affected in a predictable pattern with the use of spironolactone or in liver failure with ascites.
Choice C reason: Phosphate levels are not commonly altered by spironolactone or in ascites, and any changes would depend on other metabolic factors.
Choice D reason: Spironolactone can lead to decreased sodium levels due to its action as a diuretic that promotes sodium excretion while retaining potassium. This is particularly relevant in clients with liver failure and ascites, where fluid and electrolyte management is crucial.
Correct Answer is D
Explanation
Choice A reason: Securing the drain to the client's bed sheet is not appropriate as it does not ensure the drain is properly secured and could lead to accidental dislodgement.
Choice B reason: Measuring the drainage every hour for the first 8 hours is not standard practice. Usually, drainage measurement frequency is less frequent unless there are specific clinical concerns.
Choice C reason: Removing the JP drain should be done according to medical orders, and typically the nurse would not make the decision independently. The JP drain is usually removed when the output decreases to a minimal level and the surgeon orders its removal.
Choice D reason: Expelling the air from the JP bulb after emptying is the correct action to re-establish suction, which is necessary for the drain to function effectively.
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