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: Fine needle aspiration. This is because fine needle aspiration involves extracting cells from the lump in the breast for examination under a microscope to determine if they are cancerous. This procedure provides a definitive diagnosis of breast cancer. Breast self-examination (A) is a screening tool for detecting lumps but does not confirm a diagnosis. Mammography (C) is used for screening and detecting abnormalities but requires further testing for confirmation. Chest x-ray (D) is not useful for diagnosing breast cancer.

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 because the patient's non-verbal cues (facial grimacing) are contradicting their verbal report of low pain level. By asking the patient directly, the nurse can clarify the discrepancy and gain a better understanding of the patient's actual pain level and needs. Choice A is incorrect as it disregards the patient's observed discomfort. Choice B assumes the patient does not want pain medicine without clarifying the situation first. Choice D is premature as administering pain medication without further assessment may not be appropriate or safe. In summary, asking the patient about the facial grimacing is essential to ensure accurate pain assessment and appropriate intervention.

Correct Answer: B

Rationale: Step-by-step rationale for choice B being correct: 1. Dehydration leads to electrolyte imbalances, which can exacerbate cardiac dysrhythmias. 2. Small frequent intake of fluids like juices, broth, or milk helps in gradual rehydration without overwhelming the cardiovascular system. 3. This approach allows for better absorption of fluids and nutrients, promoting hydration without causing sudden shifts in electrolyte levels. Summary of why other choices are incorrect: A: Just drinking a glass of water every hour may not address electrolyte imbalances or provide adequate hydration for a client with cardiac dysrhythmias. C: NG replacement may not be necessary if the client can tolerate oral intake, and it is more invasive than needed. D: A rapid IV infusion may lead to sudden changes in electrolyte levels, potentially worsening the dysrhythmias.