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Questions 158

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Question 1 of 5

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

Correct Answer: C

Rationale: Epidural anesthesia can diminish bladder sensation leading to urinary retention. Hourly catheterization prevents bladder distention and complications. The other reasons are not accurate or relevant to epidural effects.

Question 2 of 5

A client with a history of endometrial cancer is admitted with complaints of vaginal bleeding. The nurse should give priority to:

Correct Answer: A

Rationale: Vaginal bleeding in endometrial cancer may indicate recurrence, so monitoring for recurrence is the priority.

Question 3 of 5

A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?

Correct Answer: A

Rationale: The first nursing measure is to instruct the client in which drug side effects to report. Discontinuing the drug is not an independent nursing intervention and may compromise client care. Audiometric testing will detect hearing loss, but it does not indicate a potential cause. Equalizing middle ear pressure will not prevent hearing loss.

Question 4 of 5

A client with a history of a burn injury is receiving Collagenase (Santyl). The nurse should:

Correct Answer: C

Rationale: Collagenase is applied to debride burn wounds, requiring a clean wound bed for effectiveness. It’s applied only to the wound, covered with a moist dressing, and not exposed to air.

Question 5 of 5

A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:

Correct Answer: D

Rationale: Phantom pain is a normal, very real experience for an amputee and should be treated with pain medication.

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