Assessment

The nurse performs a shift assessment on the patient who has been undergoing continuous bladder irrigation (CBI) following a transurethral resection of the prostate (TURP) for 3 days and notes the output to be an amber color. Which action by the nurse is most appropriate?

The nurse assesses the patient who has received continuous bladder irrigation (CBI) therapy since a transurethral resection of the prostate (TURP) 24 hours ago. Which assessment is the priority to report?  

The nurse is caring for the patient with prostate cancer and left-sided heart failure who underwent transurethral resection of the prostate (TURP) 12 hours ago. Clots are noted in the continuous bladder irrigation (CBI) outflow. Which action by the nurse is most appropriate?  

At 48 hours postop from a prostatectomy, the patient is noted to have pink output from the continuous bladder irrigation (CBI) system. Which action by the nurse is most appropriate?  

During a shift assessment 14 hours after a prostatectomy, the nurse notes bright red drainage in the continuous bladder irrigation (CBI) drainage bag. Which assessment is most important?  

The 62-year-old male patient presents to the office complaining of difficulty urinating, with a weak stream, waking multiple times in the night to urinate, and the feeling of not completely emptying the bladder that has been occurring for months. Which test must be performed first for this patient? 

The patient’s platelet level is found to be 560,000 mm³. The nurse assesses the patient for which symptoms? Select all that apply.  

The patient presents to the clinic with a chief complaint of constipation with occasional ribbon-like stools. The nurse anticipates which additional findings? Select all that apply.  

The home health nurse is assessing the patient with a colostomy. Which finding indicates the patient is performing the tap water irrigations too frequently?  

The nurse is evaluating the patient’s response to therapy with 1-deamino-8-ᴅ-arginine vasopressin (DDAVP) for treatment of mild bleeding caused by hemophilia A. Which assessment indicates the patient is experiencing an adverse effect to therapy?  

The nurse learns the previously healthy 13-year-old child was walking at school and collapsed; x-ray revealed a broken femur. The nurse is most concerned about which disorder?  

The nurse assessing the 4-month-old brought to the emergency room for poor feeding and signs of dehydration notes the infant seems to be looking down and sclera is visible superior to the iris. The nurse reports this assessment to the provider and receives orders for care. Which order does the nurse question? 

The 13-year-old girl is brought to the clinic for treatment of vaginal candidiasis for the 2nd time in 6 months. Which question is most helpful by the nurse?  

The patient in the emergency department begins projectile vomiting. Which intervention is most important?  

The 11-month-old, previously healthy infant is brought to the emergency department after becoming increasingly lethargic over the past 24 hours. The infant’s vital signs are notable for a temperature of 40.8°C, heart rate 138 bpm, respiratory rate 31, and blood pressure 84/50 mmHg. Upon assessment, the nurse notes sensitivity to light and sound, bulging anterior fontanelle, and significant resistance to turning the head. Place the interventions in the correct order.  

The 20-year-old student went on a mission trip to Ghana to help at a local hospital. She presented to the clinic 12 days after her return; she began to experience anorexia, flu-like symptoms, and fatigue. Ten days later, she noticed her eyes and skin looked yellow. Her history, assessment, and vitals are within normal limits except her yellow sclera and jaundiced skin. Initial lab studies reveal a total bilirubin of 16, indirect bilirubin of 8, AST of 1320 and ALT of 1400. The nurse prepares the patient for which test next? 

The 20-year-old healthy soccer player is brought to the emergency department after collapsing at the end of a summer soccer game. The patient is lethargic and confused about the event. Upon assessment, the nurse notes flushed, dry skin that is warm to the touch. The oral mucosa is dry, as well. Vitals are as follows: temperature 40.7°C, heart rate 122 bpm, respiratory rate 20, and blood pressure 116/64 mm Hg. A rectal thermistor is inserted and aggressive cooling measures are instituted. After 30 minutes in the ice bath, the patient’s rectal temperature is 39.1°C and the ice is partially melted. The nurse notes the rectal thermistor has stopped working; there are no other rectal thermistors in the facility. Which action by the nurse is most appropriate? 

The nurse is attempting to perform an electrocardiogram on a patient. The machine alerts the nurse that the V1, V4, and V5 electrodes are not picking up correctly. The nurse adjusts the leads in which locations? Select all that apply.  

Upon insertion of an intravenous catheter, bright red blood is noted prior to attaching the tubing. Which initial action is appropriate?