A patient who has just had a TURP asks his nurse to explain why he has to have the bladder irrigation because it seems to increase his pain. Which of the following explanations by the nurse is best?

Correct Answer: C

Rationale: Step 1: The nurse should explain that bladder irrigation is necessary to prevent blood clots from occluding the catheter after a TURP procedure. Step 2: Without irrigation, blood clots could block the catheter, leading to urinary retention and potential complications. Step 3: This explanation addresses the patient's concern about increased pain and highlights the importance of the irrigation in maintaining proper urine flow. Step 4: Choice A is incorrect because the primary purpose of irrigation is not to stop bleeding but to prevent clot formation. Choice B is incorrect because the irrigation is not for administering antibiotics. Choice D is incorrect as it does not address the issue of clot formation.

Correct Answer: C

Rationale: Step 1: The nurse should explain that bladder irrigation is necessary to prevent blood clots from occluding the catheter after a TURP procedure. Step 2: Without irrigation, blood clots could block the catheter, leading to urinary retention and potential complications. Step 3: This explanation addresses the patient's concern about increased pain and highlights the importance of the irrigation in maintaining proper urine flow. Step 4: Choice A is incorrect because the primary purpose of irrigation is not to stop bleeding but to prevent clot formation. Choice B is incorrect because the irrigation is not for administering antibiotics. Choice D is incorrect as it does not address the issue of clot formation.

Correct Answer: C

Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is important because the patient may not accurately express their pain level verbally. By addressing the discrepancy between the patient's verbal report and non-verbal cues, the nurse can gather more information to assess the patient's pain accurately. By directly communicating with the patient, the nurse can ensure that the appropriate interventions are provided. Choice A is incorrect because it disregards the need to address the patient's pain assessment. Choice B assumes the patient's preference without further clarification. Choice D jumps to administering pain medication without fully assessing the situation, which could lead to inappropriate treatment.

Correct Answer: B

Rationale: The correct answer is B. After administering glucagon for hypoglycemia, the body may deplete its glycogen stores from the liver. Offering a complex carbohydrate snack will help restore liver glycogen, preventing secondary hypoglycemia. This is crucial for maintaining blood glucose levels in individuals with type 1 diabetes. Choices A, C, and D are incorrect because offering a complex carbohydrate snack is primarily aimed at restoring liver glycogen to prevent further hypoglycemic episodes, not to address nausea/vomiting, stimulate appetite, or decrease glycogen levels.

Correct Answer: B

Rationale: The correct answer is B: Do not stop medication abruptly. Abruptly stopping propranolol can lead to rebound hypertension and potentially life-threatening complications. The nurse should emphasize the importance of gradual tapering under medical supervision to avoid adverse effects. A: Having potassium levels checked is not directly related to propranolol use for hypertension management. C: Changes in appetite are not specific to propranolol use and may not be a significant concern compared to abrupt cessation of the medication. D: Resuming usual daily activities is important but not as crucial as the correct instruction to avoid abrupt discontinuation of propranolol.

Correct Answer: B

Rationale: The correct answer is B: Administering platelets, as ordered to maintain an adequate platelet count. In ITP, the client has low platelet count leading to risk of bleeding. Administering platelets helps raise platelet levels and prevent bleeding complications. Teaching coughing and deep-breathing techniques (A) is important for preventing respiratory infections but not directly related to ITP. Giving aspirin (C) is contraindicated as it can further decrease platelet count. Administering stool softeners (D) is important for preventing straining but not specific to managing ITP.

Correct Answer: A

Rationale: The correct answer is A: Decreased resistance to infection. Lymphocytes are a crucial part of the immune system, responsible for fighting off infections. A decrease in the number of lymphocytes with age leads to a weakened immune response, making individuals more susceptible to infections. - Choice B: Cognitive problems, is not directly related to lymphocyte levels. - Choice C: Urinary incontinence, is not a typical effect of decreased lymphocytes. - Choice D: Decrease in various blood components, is too broad and not specific to the role of lymphocytes in immunity.

Correct Answer: D

Rationale: The correct answer is D: Autoimmune reaction. Guillain-Barre Syndrome is an autoimmune disorder where the immune system mistakenly attacks the peripheral nerves, leading to muscle weakness and paralysis. This is supported by the patient's presentation of weakness in the legs. Bacterial infection (A) can trigger Guillain-Barre Syndrome, but it is not the root cause. High-fat diet (B) and heredity (C) are not associated with the development of this syndrome. In summary, autoimmune reaction is the primary mechanism underlying Guillain-Barre Syndrome, resulting in the patient's muscle weakness and inability to walk.

Correct Answer: D

Rationale: The correct answer is D. Epinephrine, when applied locally, constricts blood vessels, reducing blood flow and slowing down bleeding. This vasoconstrictive effect helps control nosebleeds effectively. Choice A is incorrect because although epinephrine can raise blood pressure, it is not the primary mechanism for treating nosebleeds. Choice B is incorrect as epinephrine's bronchodilation effect is not relevant in this context. Choice C is incorrect as while promoting blood clotting is beneficial, epinephrine primarily acts by vasoconstriction to control bleeding.