The day after a radical prostatectomy, your client had blood clots in the urinary catheter and reports bladder spasms. The client says that his right calf is sore and that he feels short of breath. Which action will you take first?
A. Irrigate the catheter with 50 mL of sterile saline
B. Administer oxybutynin (Ditropan) 5 mg orally
C. Apply warm packs to the client's right calf
D. Measure oxygen saturation using a pulse oximetry
Answer: D. Measure oxygen saturation using a pulse oximetry
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The student is caring for a client on the first day in the clinical setting. The student coveys respect for the client by all of the following except:
1. Communicating appropriately with the client. 2. Asking the unlicensed assistive person to answer the client's call bell. 3. Arriving at clinical in professional attire. 4. Caring for the client in an unhurried manner.
One bed is available on the eating disorders unit. Which patient should be admitted? The patient whose assessment findings show the weight dropped from:
a. 150 to 102 pounds over a 4-month period. Vital signs: temperature, 96.1° F; pulse, 38 beats/min; blood pressure 64/42 mm Hg. b. 120 to 90 pounds over a 3-month period. Vital signs: temperature, 97.2° F; pulse, 50 beats/min; blood pressure 70/50 mm Hg. c. 110 to 70 pounds over a 4-month period. Vital signs: temperature 97.6° F; pulse, 60 beats/min; blood pressure 80/66 mm Hg. d. 90 to 78 pounds over a 5-month period. Vital signs: temperature, 98.6° F; pulse, 62 beats/min; blood pressure 74/48 mm Hg.
The nurse shows an understanding of the psychosocial impact of bladder and/or bowel incontinency when prior to going to the dining room for meals each individual experi-encing incontinence:
a. is assessed for soiled clothing and changed if necessary b. is toileted and then is promptly moved to the dining room c. is provided peri-care and fresh underclothing is provided d. is asked if toileting is needed and assisted as necessary
MC The nurse is working with a group of elderly clients who were affected by the largest hurricane on record. The clients admit to many psychological responses,
from confusion to hysteria. The nurse informs the group that the number of months it takes most people to psychologically recover from a disaster is: A. Six to eight. B. Two to three. C. Four to six. D. Six to twelve.