A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?

Correct Answer: C

Rationale: The correct answer is C: Red-tinged urine with numerous clots. This finding should be reported because it indicates excessive bleeding following a TURP procedure. Passing small clots in the urine (choice A) is expected post-TURP. Continuous bladder irrigation (choice B) is a standard procedure after TURP to prevent clot retention. Urine output of 50 mL/hr (choice D) is within the expected range postoperatively and does not indicate a complication.

Correct Answer: B

Rationale: Correct Answer: The healthcare professional should review serum creatinine levels before administering metformin to assess kidney function. Metformin is excreted by the kidneys, and checking serum creatinine helps prevent lactic acidosis, a potential side effect in individuals with impaired renal function. Choice A: Potassium levels are not directly related to the administration of metformin. While monitoring potassium levels is important for some medications, it is not the priority when initiating metformin. Choice C: Sodium levels are not typically assessed specifically before starting metformin. It is not a routine lab test required prior to metformin administration. Choice D: Hemoglobin A1C reflects long-term blood sugar control and is not a lab test that needs to be reviewed before initiating metformin. It is used to monitor diabetes management over time, not for immediate medication administration considerations.

Correct Answer: B

Rationale: The correct action for the nurse to take is to assess the client's lung sounds before administering IV fluids. This is crucial to identify any signs of fluid overload, such as crackles or wheezes. Administering the solution slowly over 24 hours (choice A) is not appropriate for an IV bolus, which is a rapid infusion. Changing the IV tubing every 12 hours (choice C) is a standard practice for preventing infection but is not directly related to administering an IV bolus. Flushing the IV line with heparin every 4 hours (choice D) is a maintenance practice to prevent clot formation in the line, not specifically related to administering an IV bolus.

Correct Answer: A

Rationale: Correct Answer: Chicken breast. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Foods high in potassium, like spinach and yogurt, should be avoided when taking spironolactone to prevent hyperkalemia. Chicken breast, being a low-potassium protein source, is a suitable recommendation for clients on spironolactone therapy.

Correct Answer: D

Rationale: In a client with a history of angina experiencing chest pain radiating to the left arm, obtaining a 12-lead ECG is the priority action to assess for myocardial infarction. An ECG helps in diagnosing and evaluating the extent of cardiac ischemia or infarction. Administering nitroglycerin, oxygen, or aspirin can follow once the ECG has been performed to confirm the diagnosis and guide further interventions. Administering nitroglycerin sublingually is often appropriate for angina but should not precede the ECG in this urgent scenario. Oxygen therapy and aspirin administration are important interventions but obtaining the ECG takes precedence in assessing for acute cardiac events.

Correct Answer: A

Rationale: The correct answer is to monitor INR for a patient on warfarin therapy. INR monitoring is crucial as it helps assess the therapeutic effectiveness and safety of warfarin. INR stands for International Normalized Ratio, and it measures the blood's ability to clot. Monitoring potassium levels (Choice B) is not specific to warfarin therapy. Monitoring platelet count (Choice C) is important but not the primary lab value for assessing warfarin therapy. Monitoring sodium levels (Choice D) is not directly related to warfarin therapy.

Correct Answer: D

Rationale: The correct answer is D, decreased platelet count. In disseminated intravascular coagulation (DIC), there is widespread activation of clotting factors leading to the formation of multiple blood clots throughout the body, which can deplete platelets. A decreased platelet count is a hallmark of DIC. Elevated hemoglobin (choice A) and elevated white blood cell count (choice B) are not specific indicators of DIC. While fibrinogen levels (choice C) can be decreased in DIC due to consumption, a decreased platelet count is a more specific and early sign of DIC development.

Correct Answer: A

Rationale: The appropriate nursing action for a patient experiencing an acute allergic reaction is to administer antihistamines. Antihistamines work by blocking the action of histamine, a chemical released during an allergic reaction, and can help relieve symptoms such as itching, swelling, and hives. Corticosteroids are used for severe allergic reactions not responding to antihistamines, as they have anti-inflammatory properties. Oxygen is administered in cases of respiratory distress, while bronchodilators are used for bronchospasms. However, the first-line intervention for an acute allergic reaction is antihistamines.

Correct Answer: A

Rationale: The correct action when digitally evacuating a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and effectively dislodge the impacted stool. Choice B, applying lubricant and stimulating peristalsis, is incorrect as it does not directly address the evacuation of the impacted stool. Choice C, applying pressure to the abdomen, is inappropriate and may cause discomfort or harm to the client. Choice D, increasing fluid intake before the procedure, is not directly related to the immediate evacuation of the fecal impaction.