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Questions 149

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Question 1 of 5

The physician has ordered continuous bladder irrigation for a client following a prostatectomy. The nurse should:

Correct Answer: A

Rationale: Hanging the solution 2-3 feet above the abdomen ensures proper flow by gravity without excessive pressure, maintaining effective irrigation.

Question 2 of 5

The nurse is caring for a client who is postoperative day 1 following a mastectomy. The client refuses to look at the surgical site or participate in wound care teaching. Which of the following actions by the nurse is MOST appropriate?

Correct Answer: A

Rationale: encouraging the client to express feelings promotes coping and addresses potential body image concerns

Question 3 of 5

The nurse is assessing a client with an altered level of consciousness. One of the first signs of altered level of consciousness is:

Correct Answer: C

Rationale: Restlessness is often an early sign of altered consciousness, indicating neurological changes before more severe symptoms appear.

Question 4 of 5

During a pre-op assessment, the nurse would chart which finding(s) as subjective data? Select all that apply.

Correct Answer: B,C,E

Rationale: Subjective data are client-reported, including statements about surgery concerns, weight loss, and pain ratings. Sweating/wringing hands and blood pressure are objective (observable/measurable).

Question 5 of 5

A 46-year-old male has been placed under therapeutic hypothermic care after a myocardial infarction (MI). The nurse correctly explains to the family,

Correct Answer: C

Rationale: Therapeutic hypothermia post-MI slows metabolism, reducing cerebral oxygen demand and protecting the brain from ischemic injury.

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