Question

A nurse is caring for a postoperative client following a perineal prostatectomy.

Answer 1

Correct Answers

Apply warm compresses to the incision site. [ Anticipated ]
Maintain bed rest for 2 days postoperatively. [ Contraindicated ]
Irrigate indwelling urinary catheter with 50 mL of normal saline. [ Contraindicated ]
Administer enema to relieve constipation. [ Contraindicated ]
Place a blanket roll under the client’s knees while in bed. [ Contraindicated ]

Rationale :

🟢 Apply warm compresses to the incision site

🔹 Warm compresses are an appropriate comfort intervention that promotes localized vasodilation, reducing swelling and discomfort at the incision site.

🔹 This non-invasive method improves circulation, accelerates healing, and minimizes the need for systemic analgesics.

🔹 It aligns with standard postoperative care protocols and does not compromise the surgical site.

🟢 Maintain bed rest for 2 days postoperatively

🔹 Prolonged bed rest increases the risk of venous thromboembolism, pneumonia, and deconditioning in postoperative clients.

🔹 Early ambulation is encouraged after prostatectomy to stimulate circulation, support bowel motility, and reduce respiratory complications.

🔹 Bed rest for 2 days is no longer a best practice in post-surgical recovery unless complications are present.

🟢 Irrigate indwelling urinary catheter with 50 mL of normal saline — Contraindicated

🔹 Catheter irrigation without a specific provider order is not recommended because it may introduce pathogens and disrupt the bladder or urethral mucosa.

🔹 This can lead to infection or trauma, especially in a surgical area where healing is ongoing.

🔹 Continuous bladder irrigation (CBI) may be ordered but must follow strict aseptic technique and protocols.

🟢 Administer enema to relieve constipation

🔹 Enemas can increase intra-abdominal and pelvic pressure, which may disrupt the surgical site and increase the risk of bleeding or wound dehiscence.

🔹 Post-prostatectomy clients are vulnerable to pelvic trauma, so bowel interventions should be gentle—stool softeners or dietary fiber are preferred.

🔹 Invasive rectal procedures are avoided unless absolutely necessary.

🟢 Place a blanket roll under the client’s knees while in bed

🔹 Using a knee roll can cause venous stasis, impairing circulation and increasing the risk of deep vein thrombosis (DVT).

🔹 This positioning can also contribute to joint stiffness or contractures, especially in immobile clients.

🔹 Optimal positioning involves the client lying flat or slightly elevated without prolonged knee flexion.

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Answer 2

Correct Answers

Stay with the client for the first 15 min of the transfusion. [ Indicated ]
Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg. [ Not Indicated ]
Document the blood product transfusion in the client's medical record. [ Indicated ]
Obtain the first unit of packed RBCs from the blood bank. [ Indicated ]
Start an IV bolus of lactated Ringer's solution. [ Not Indicated ]

Rationale :

🟢 Stay with the client for the first 15 minutes of the transfusion

🔹 The first 15 minutes of transfusion is the critical window for identifying acute transfusion reactions, including fever, chills, back pain, hypotension, or anaphylaxis.

🔹 Close monitoring allows for immediate discontinuation and intervention if a reaction occurs.

🔹 This is a standard nursing protocol and essential for patient safety during transfusions.

🔴 Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg

🔹 Adjusting blood transfusion rate based on blood pressure targets is not safe practice, as it may lead to fluid overload or hemolysis.

🔹 Blood should be infused at a prescribed rate according to institutional protocol and patient tolerance, not to manipulate vital signs.

🔹 Blood products should never be used to treat hypotension directly; other interventions should be ordered if needed.

🟢 Document the blood product transfusion in the client’s medical record — Indicated

🔹 Documentation of blood transfusion includes start/stop time, blood product type, amount infused, vital signs, and client response.

🔹 Accurate charting ensures continuity of care, legal protection, and supports post-transfusion monitoring.

🔹 It also provides data for future compatibility and clinical decisions.

🟢 Obtain the first unit of packed RBCs from the blood bank

🔹 Retrieving the unit is a necessary preparatory step to ensure the correct, compatible blood is available and safely stored until use.

🔹 The nurse must verify identification, expiration date, and product integrity prior to administration.

🔹 Though this is a pre-transfusion step, it is an essential part of the transfusion workflow.

🔴 Start an IV bolus of lactated Ringer’s solution

🔹 Lactated Ringer’s solution is incompatible with blood products and can lead to hemolysis or clotting within the infusion line.

🔹 Only 0.9% sodium chloride (normal saline) should be used during transfusions to maintain patency.

🔹 Using the wrong IV fluid jeopardizes client safety and violates transfusion standards.

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Answer 3

Correct Answers

Insert an indwelling urinary catheter. [ Contraindicated ]
Insert a nasogastric tube and maintain low intermittent suction. [ Contraindicated ]
Administer lactated Ringer’s 1 L via IV bolus. [ Contraindicated ]
Administer famotidine 20 mg via intermittent IV infusion twice daily. [ Contraindicated ]

Rationale :

🟢 Insert an indwelling urinary catheter

🔵 In acute pancreatitis, especially with signs of hypovolemia and tachycardia, close monitoring of urine output is essential to assess kidney perfusion and fluid resuscitation effectiveness.

🔵 An indwelling catheter provides accurate hourly output measurement, which guides ongoing fluid and electrolyte management.

🔵 It helps detect early signs of renal compromise and supports critical care documentation.

🟢 Insert a nasogastric tube and maintain low intermittent suction

🔵 Pancreatitis often causes nausea, vomiting, and gastric distension, which can worsen abdominal pain and increase the risk of aspiration.

🔵 NG decompression reduces pancreatic stimulation, rest the GI tract, and decreases the risk of aspiration pneumonia.

🔵 This is a standard supportive intervention, especially in severe cases or when the client cannot tolerate oral intake.

🟢 Administer lactated Ringer’s 1 L via IV bolus

🔵 The client shows signs of hypovolemia (high heart rate, dry mucosa, low BP), likely due to third-spacing and vomiting.

🔵 Lactated Ringer’s is the preferred fluid in acute pancreatitis for volume resuscitation and electrolyte replacement.

🔵 Early aggressive IV hydration helps prevent complications like shock, renal failure, and pancreatic necrosis.

🟢 Administer famotidine 20 mg via intermittent IV infusion twice daily

🔵 Famotidine, a histamine-2 blocker, reduces gastric acid secretion, which helps minimize pancreatic stimulation and protects the GI mucosa.

🔵 Clients with pancreatitis are often NPO and at risk for stress ulcers; acid suppression reduces this risk.

🔵 It is a routine part of medical management for acute pancreatitis or critically ill clients.

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Answer 4

Correct Highlights :

I found the title to the car today, signed over to me."
Client's child reports their parent has lost about 8 lb in the past month.
Client says. "Why don't you just leave me? I am of no use.”
"Client reports not wanting to eat anymore.
Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression.

Rationale :

"I found the title to the car today, signed over to me."

🔴 This raises concern for possible elder financial exploitation.

🔴Sudden transfer of valuable assets (like a car title) without clear consent can indicate abuse or coercion, especially in a cognitively impaired individual.

Client reports not wanting to eat anymore.

🔴 Anorexia in older adults can signify underlying depression, illness, or neglect and requires prompt assessment due to risk of malnutrition.

Client's child reports their parent has lost about 8 lb in the past month.

🔴 Unintentional weight loss of more than 5% in 1 month is a red flag for physical decline, depression, cancer, or cognitive disorders and needs immediate medical and nutritional evaluation.

Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression.

🔴 These are hallmark signs of major depressive disorder and may also be linked to Parkinsonism or neurologic decline.

🔴 Immediate follow-up is needed to evaluate mental health and cognitive status.

Client says, "Why don't you just leave me? I am of no use.”

🔴 This is a suicidal ideation cue and represents a psychiatric emergency.

🔴Hopelessness and statements of worthlessness must be assessed immediately for suicide risk, especially in older adults with depression.

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Answer 5

Correct Answers:

Isolate the client from staff who are pregnant.

Rationale :

🟣 Rubella poses a serious risk to fetal development, especially during the first trimester. Pregnant staff should avoid contact with infected clients to prevent congenital rubella syndrome, which can result in deafness, cataracts, heart defects, and developmental delays in the fetus.

🟣 This precaution protects both the client and unborn children and aligns with standard infection control practices.

🟣 Rubella is transmitted through respiratory droplets, so droplet precautions are sufficient—airborne precautions are unnecessary, and Koplik spots are not a feature of rubella.

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Answer 6

Correct Answers:

Remove the cap and place it sterile-side up on a clean surface.

Rationale :

🔵 When pouring sterile solutions, the cap should be placed sterile side up to maintain sterility and prevent contamination.

🔵 The bottle must be held with the label facing the palm to prevent smearing the label if liquid drips.

🔵 Holding the bottle over the sterile field or placing gauze on spills contaminates the field, necessitating setup of a new sterile area.

🔵 These steps preserve the integrity of the sterile field and prevent infection.

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Answer 7

Correct Answers:

Identify possible precipitating factors related to the infections.

Rationale :

🟢 The initial step in addressing a rise in catheter-associated infections is to conduct a root cause analysis.

🟢 Identifying whether the increase is due to issues such as inadequate hand hygiene, prolonged catheter use, or poor insertion technique is essential for targeted interventions.

🟢 Without first analyzing contributing factors, subsequent actions like training or policy changes may miss the actual problem.

🟢 A data-driven assessment ensures that efforts to reduce infections are both effective and evidence-based.

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Answer 8

Correct Answers:

administer sublingual nitroglycerin

Rationale :

🔴 Chest pain in a client with elevated troponin and abnormal lipid levels should prompt immediate intervention to restore coronary perfusion.

🔴 Sublingual nitroglycerin acts as a vasodilator, reducing myocardial oxygen demand and relieving ischemic pain quickly.

🔴 This is the priority before further diagnostic or secondary pharmacologic interventions, such as beta-blockers or repeated troponin levels.

🔴 Administering nitroglycerin promptly can help prevent infarction progression and stabilize the client's condition.

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Answer 9

Correct Answers:

Administering potassium via IV bolus.

Rationale :

🟠 Administering IV potassium as a bolus is a severe breach of nursing standards due to the risk of fatal arrhythmias. Potassium must be diluted and infused slowly via pump with cardiac monitoring.

🟠 This act is a classic example of malpractice, which involves deviation from the standard of care leading to patient harm.

🟠 Mistakes like clamping NG tubes or failing to label fall-risk patients are errors, not malpractice, unless harm results.

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Answer 10

Correct Answers:

Increase exercise.

Rationale :

🟢 Opioid medications commonly slow gastrointestinal motility, increasing the risk for opioid-induced constipation, a significant side effect in chronic pain management.

🟢 Increasing physical activity can stimulate bowel movements and promote regular elimination patterns.

🟢 Non-pharmacologic methods like exercise, increased fluid intake, and a high-fiber diet are first-line strategies to prevent dependency on laxatives.

🟢 Nurses should include activity in their teaching plan as part of a comprehensive bowel regimen to support safe and effective long-term opioid use.

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Options	Anticipated	Contraindicated
Apply warm compresses to the incision site.
Maintain bed rest for 2 days postoperatively.
Irrigate indwelling urinary catheter with 50 mL of normal saline.
Administer enema to relieve constipation.
Place a blanket roll under the client’s knees while in bed.

Options	Indicated	Not Indicated
Stay with the client for the first 15 min of the transfusion.
Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
Document the blood product transfusion in the client's medical record.
Obtain the first unit of packed RBCs from the blood bank.
Start an IV bolus of lactated Ringer's solution.

Anticipated	Contraindicated
Insert an indwelling urinary catheter.
Insert a nasogastric tube and maintain low intermittent suction.
Administer lactated Ringer’s 1 L via IV bolus.
Administer famotidine 20 mg via intermittent IV infusion twice daily.

QLexNursing

1 :
A nurse is caring for a postoperative client following a perineal prostatectomy.

Correct Answers

🟢 Apply warm compresses to the incision site

🟢 Maintain bed rest for 2 days postoperatively

🟢 Irrigate indwelling urinary catheter with 50 mL of normal saline — Contraindicated

🟢 Administer enema to relieve constipation

🟢 Place a blanket roll under the client’s knees while in bed

2 :
The nurse reviews the entries in the medical record.

Correct Answers

🟢 Stay with the client for the first 15 minutes of the transfusion

🔴 Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg

🟢 Document the blood product transfusion in the client’s medical record — Indicated

🟢 Obtain the first unit of packed RBCs from the blood bank

🔴 Start an IV bolus of lactated Ringer’s solution

3 :
A nurse in an emergency department is caring for a client.

Correct Answers

🟢 Insert an indwelling urinary catheter

🟢 Insert a nasogastric tube and maintain low intermittent suction

🟢 Administer lactated Ringer’s 1 L via IV bolus

🟢 Administer famotidine 20 mg via intermittent IV infusion twice daily

4 :
A nurse is caring for an older adult client.

Correct Highlights :

5 :
A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?

6 :
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

7 :
A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

8 :
A nurse is caring for a client with chest pain. Laboratory Results

Answer Options

9 :
A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

10 :
A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

QLexNursing

1 : A nurse is caring for a postoperative client following a perineal prostatectomy.

Correct Answers

🟢 Apply warm compresses to the incision site

🟢 Maintain bed rest for 2 days postoperatively

🟢 Irrigate indwelling urinary catheter with 50 mL of normal saline — Contraindicated

🟢 Administer enema to relieve constipation

🟢 Place a blanket roll under the client’s knees while in bed

2 : The nurse reviews the entries in the medical record.

Correct Answers

🟢 Stay with the client for the first 15 minutes of the transfusion

🔴 Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg

🟢 Document the blood product transfusion in the client’s medical record — Indicated

🟢 Obtain the first unit of packed RBCs from the blood bank

🔴 Start an IV bolus of lactated Ringer’s solution

3 : A nurse in an emergency department is caring for a client. ​​​​​​

Correct Answers

🟢 Insert an indwelling urinary catheter

🟢 Insert a nasogastric tube and maintain low intermittent suction

🟢 Administer lactated Ringer’s 1 L via IV bolus

🟢 Administer famotidine 20 mg via intermittent IV infusion twice daily

4 : A nurse is caring for an older adult client.

Correct Highlights :

5 : A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?

6 : A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

7 : A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

8 : A nurse is caring for a client with chest pain. Laboratory Results

Answer Options

9 : A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

10 : A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

1 :
A nurse is caring for a postoperative client following a perineal prostatectomy.

2 :
The nurse reviews the entries in the medical record.

3 :
A nurse in an emergency department is caring for a client.

4 :
A nurse is caring for an older adult client.

5 :
A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?

6 :
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

7 :
A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

8 :
A nurse is caring for a client with chest pain. Laboratory Results

9 :
A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

10 :
A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?