Question

A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

Answer 1

Correct Answers:

Remind the client he might feel a constant urge to void.

Rationale :

🟩 Following a transurethral resection of the prostate (TURP) with continuous bladder irrigation (CBI), it is normal for clients to feel a persistent urge to void.

🟩 This occurs due to bladder spasms and catheter presence, not necessarily because the bladder is full.🟩 Educating the client about this helps reduce anxiety and unnecessary straining, which could disrupt the surgical site or catheter.

🟩 Monitoring output is essential, but it should occur more frequently than every 6 hours, and fluids should be encouraged to maintain urine flow and prevent clot formation.

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Answer 2

Correct Answers:

Norepinephrine intravenous (IV) infusion

Rationale :

🟨 In septic shock, if hypotension persists after fluid resuscitation (e.g., 2,500 mL of lactated Ringer’s), the next step is the initiation of a vasopressor.

🟨 Norepinephrine is the first-line agent recommended to increase systemic vascular resistance and blood pressure while maintaining organ perfusion.

🟨 It works primarily via alpha-adrenergic stimulation, causing vasoconstriction.

🟨 Epinephrine and dobutamine are less preferred for initial therapy, and dexamethasone is not a treatment for hypotension in this context.

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Answer 3

Correct Answers:

"l will keep the temperature in my house cold to avoid becoming overheated."

Rationale :

✍️In systemic lupus erythematosus (SLE), cold environments can trigger flares and worsen symptoms like joint stiffness and fatigue.

✍️ Clients need to be taught that both excessive cold and sun exposure can provoke symptoms.

✍️ Protective clothing, stress reduction, and medication adherence are key strategies for flare prevention.

✍️ This statement reflects a misunderstanding and thus indicates a need for further teaching.

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Answer 4

Correct Answers:

Increased respiratory rate

Rationale :

💎 An increased respiratory rate is often the earliest physiologic indicator of shock, even before hypotension or altered mental status.

💎 The body compensates for reduced tissue perfusion by attempting to increase oxygen delivery and remove CO₂.

💎This makes tachypnea a critical early warning sign.

💎Waiting for hypotension or anuria delays diagnosis, as those reflect advanced shock.

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Answer 5

Correct Answers:

Administer the medications 5 minutes apart

Rationale :

▶ When administering multiple types of eye drops like timolol (a beta-blocker) and pilocarpine (a miotic) for open-angle glaucoma.

▶ The medications should be given at least 5 minutes apart.

▶ This spacing prevents washout of the first medication and ensures proper ocular absorption.

▶ Drying the sclera is unnecessary, and contact with the dropper tip can cause contamination or injury.

▶ Applying pressure should be to the nasolacrimal duct, not the conjunctival sac, and only for about 1 minute.

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Answer 6

Correct Answers:

Scrambled eggs

Rationale :

⫸ Meniere’s disease involves abnormal fluid accumulation in the inner ear and is managed partly by dietary changes to reduce fluid retention.

⫸ Clients are advised to consume a low-sodium diet, as sodium exacerbates endolymphatic pressure, worsening symptoms like vertigo, tinnitus, and hearing loss.

⫸ Baked ham, cheese pizza, and chicken noodle soup are all high in sodium, making them inappropriate. ⫸ Scrambled eggs, if prepared without added salt, are a safe, low-sodium protein source.

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Answer 7

Correct Answers:

Reduce the client's intake of protein.

Rationale :

🔶 In end-stage liver disease with hepatic encephalopathy, ammonia accumulates in the body due to impaired liver detoxification.

🔶 Protein is metabolized into ammonia, so reducing dietary protein can help limit ammonia production.

🔶 Protein restriction is controversial long-term in acute settings; lowering protein intake reduces neurological symptoms like confusion and agitation.

🔶 Diuretics manage ascites but don't reduce ammonia, and sodium restriction is more for fluid retention. Vitamin K corrects coagulopathy, not encephalopathy.

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Answer 8

Correct Answers:

Performing hand hygiene before, during, and after direct contact with the client

Rationale :

📚 Hand hygiene is the most effective method for preventing healthcare-associated infections (HAIs).

📚 Performing hand hygiene before, during, and after contact with clients, equipment, or body fluids interrupts the transmission of microorganisms.

📚 Changing linens and placing patients in specialized airflow rooms are not routinely required for all infections and depend on isolation type.

📚 Blood glucose control helps immune function but is not an immediate infection prevention strategy.

📚 By enforcing proper handwashing, nurses play a vital role in infection control and client safety.

👉 Always start infection prevention with clean hands.

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Answer 9

Correct Answers:

Vitamin K

Rationale :

🔹 Clients with chronic liver failure often experience spontaneous bleeding and bruising due to impaired synthesis of clotting factors, most of which are vitamin K–dependent (e.g., II, VII, IX, X).

🔹The liver also stores and activates vitamin K, and in its failure, deficiency contributes to coagulopathy. 🔹 Vitamin K supplementation aids in restoring clotting capacity.

🔹Thiamine addresses Wernicke's encephalopathy, vitamin C affects tissue healing, and folic acid supports red blood cell production but not coagulation.

🔹This makes vitamin K the most directly relevant intervention for spontaneous bleeding in liver failure.

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Answer 10

Correct Answers:

Keep a body map of skin lesions

Rationale :

📚 Clients at risk for skin cancer should be taught to perform monthly skin self-exams and maintain a body map to monitor new or changing lesions.

📚Keeping a visual record helps in the early detection of melanoma or other skin malignancies, which is critical for successful treatment.

📚 Exams every 2 months are not frequent enough, and avoiding sun after 3 p.m. is less helpful since UV radiation is most intense before 3 p.m.

📚 Tanning bed use should be eliminated, not just reduced.

🔹A consistent skin-check system increases early diagnosis and saves lives.

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RN Medsurg II Nur258 Final Exam

No.

1 : A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

2 : A nurse is caring for a client in septic shock. The client is still hypotensive and lethargic following a 2,500 mL fluid bolus of lactated Ringer (LR) solution. Which of the following interventions does the nurse anticipate next?

3 : A nurse is teaching a female client with systemic lupus erythematosus (SLE) about exacerbating factors for their disease. Which statement about exacerbating factors by the client requires further teaching?

4 : A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

5 : A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?

6 : A client with Meniere disease is instructed to modify his diet. The nurse would explain which item would be acceptable for the client to include.

7 : A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

8 : A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?

9 : A nurse is assessing a client with chronic liver failure who tells the nurse he is experiencing spontaneous episodes of bleeding and has noted increased areas of bruising on his arms. The nurse suspects the client has a deficiency in which of the following vitamins?

10 : A nurse is developing an education program about skin cancer for a community center. Which of the following instructions should the nurse plan to include?

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