A.B. returns status post–laparoscopic radical prostatectomy (LRP). Initial postoperative orders are written
Which orders are appropriate for A.B.? Select all that apply, and correct the inappropriate
answers.
a. Vital signs per hospital protocol
b. Notify physician if urinary output is less than 30 mL/hr
c. Up ad lib
d. Change Foley catheter if clotting occurs
e. Oxybutynin (Ditropan XL) 10 mg PO every morning
f. Docusate (Colace) 100 mg PO qd
g. Morphine 4 mg IV push q4h prn pain
a, b, e, f, g
Answer c is incorrect. He can get up as tolerated but only with assistance to ensure that there is
no tension on the urinary catheter. In addition, he might be receiving an opioid (morphine) for pain,
and he could be at risk for falling. Answer d is incorrect. Do not remove the Foley catheter under any
circumstances. The surgical area could be disrupted, and bleeding might occur.
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Sarcoidosis is an autoimmune disease that presents with non-specific symptoms of fatigue, fever, and arthralgias. Which of the following signs should raise suspicion of this disorder?
A. Facial rash across nose and cheeks B. Bilateral hilar lymphadenopathy on chest x-ray C. Specific tender points on the body D. Swelling of metacarpophalangeal joints
An appropriate nursing measure when a baby has an unexpected anomaly is to
a. Remove the baby from the delivery area immediately. b. Tell the parents that the baby has to go to the nursery immediately. c. Inform the parents immediately that something is wrong. d. Explain the defect and show the baby to the parents as soon as possible.
A public health nurse uses collaboration, coalition building, and community organizing when:
a. Providing case management, referral, and follow-up services with individuals b. Carrying out collective action at the systems or community levels of practice c. Conducting a community assessment d. Implementing primary and secondary prevention strategies
The client has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximum oxygenation, an appropriate action by the nurse is to:
1. Suction continuously for 30-second intervals 2. Replace the oxygen and allow rest in between suctioning passes 3. Increase the amount of suction pressure to 200 mm Hg 4. Complete a number of suctioning passes until the catheter comes back clear