A patient tells his nurse that he has delayed having TURP because he is afraid it will affect his sexual function. Which response by the nurse is most appropriate?

Correct Answer: C

Rationale: The most appropriate response by the nurse is option C, "This type of surgery rarely affects the ability to have an erection or ejaculation." This response is accurate and provides reassurance to the patient while acknowledging his concerns. Transurethral resection of the prostate (TURP) is a common procedure for managing benign prostatic hyperplasia (BPH), and it typically does not have a significant impact on sexual function. By providing this information, the nurse can help alleviate the patient's fears and encourage him to proceed with the necessary treatment.

Correct Answer: C

Rationale: Normal serum osmolality typically ranges between 280 to 295mOsm/kg. Serum osmolality reflects the concentration of solute particles in the blood, including sodium, glucose, and blood urea nitrogen. Sodium is a major determinant of serum osmolality, but it is not the only factor. In this case, since the patient's serum sodium is within the normal range, the nurse can reasonably estimate that the serum osmolality would fall within the normal range of 280 to 295mOsm/kg. Options A, B, and D are outside the typical range for serum osmolality in a healthy individual.

Correct Answer: C

Rationale: Nursing assessment for a patient with metabolic alkalosis includes evaluation of laboratory data for hypocalcemia, hypokalemia, and hypoxemia as these are commonly associated with this acid-base imbalance. Hypoglycemia, on the other hand, is not typically linked with metabolic alkalosis and is not commonly assessed in this context. Therefore, hypoglycemia would not be a key focus of nursing assessment in a patient with metabolic alkalosis.

Correct Answer: A

Rationale: Suctioning a tracheostomy tube is a procedure that requires proper technique to prevent complications. Hyperventilating James with 100% oxygen before and after suctioning indicates that Wilma is committing an error. The correct approach is to provide pre-oxygenation with 100% oxygen for at least two minutes before suctioning to prevent hypoxemia. However, hyperventilation with 100% oxygen can lead to oxygen toxicity, which can be harmful to the patient. The other options, instilling normal saline to loosen secretions, applying suction during catheter withdrawal, and suctioning the client every hour are appropriate techniques when performing tracheostomy tube suctioning.

Correct Answer: C

Rationale: The patient with kidney failure is most at risk for fluid volume overload because the kidneys are responsible for regulating fluid balance in the body. In kidney failure, the kidneys are unable to effectively filter and excrete excess fluids, leading to an accumulation of fluid in the body. This can result in fluid volume overload, which can be dangerous and lead to complications such as pulmonary edema, congestive heart failure, and hypertension. It is important to monitor this patient closely for signs and symptoms of fluid overload and manage their fluid intake carefully.