The nurse is caring for a client receiving continuous bladder irrigation following transurethral prostatectomy. When emptying the urine collection bag, the nurse notes that 500 mL of irrigant has infused with only 100 mL of drainage returned
Which is the priority action by the nurse?
1. Irrigating the outflow port using an irrigation syringe to determine patency
2. Notifying the health care provider immediately
3. Irrigating the irrigation port to determine patency
4. Continuing to monitor output
Correct Answer: 1
The outflow port that drains urine and irrigation fluid from the bladder should be irrigated gently to assure patency. If the port is blocked, the nurse should not apply excessive pressure but should notify the health care provider. The fluid is continuing to flow into the bladder, so there is no indication the irrigation port is blocked, making irrigation of this port unnecessary. Continuing to monitor output, without resolving the issue, could result in trauma to the client's bladder.
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The nurse is teaching a male client with a spinal cord injury at T4 (thoracic) about the sexual effects of this injury. Which statement by the client indicates correct understanding of the teach-ing? (Select all that apply.)
a. "I will not be able to have an erection be-cause of my injury." b. "Ejaculation may not be as predictable as before." c. "I will explore other ways besides inter-course to please my partner." d. "I may urinate with ejaculation but this will not cause an infection." e. "I should be able to have an erection with stimulation."
The best cure for pressure ulcers is
A. anti-inflammatory drugs. B. prevention. C. antibiotics. D. protectants.
The nurse is writing a plan of care for a patient newly admitted to the floor with an asthma attack that occurred while exercising. What would be the most appropriate intervention for this patient?
A) Assist patients with moderate to severe asthma in obtaining a home nebulizer unit B) Try to prevent or reduce panic, which may initiate bronchospasm C) Teach patient to use an inhaler before exercising D) Monitor peak flow rates, especially in children
A 79-year-old female patient, admitted for hip replacement surgery, complained of insomnia the night before and was administered lorazepam, a benzodiazepine
She began displaying signs of delirium shortly thereafter, a situation that has persisted until the morning change of shift. Which of the following guidelines should the night nurse provide to the nurse coming on shift to care for the patient? A) "Make sure you get a sedative order from her doctor this morning.". B) "Try to keep her level of stimulation as low as you can when you are working with her.". C) "Make sure you let the family know that there are effective drug treatments that will resolve her delirium.". D) "Work with the discharge-planning nurse to help the family reassess her living arrangement after discharge.".