Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take?

Correct Answer: D

Rationale: A temperature of 101°F after cardiac surgery in a young child, especially 72 hours post-surgery, is a concerning finding that should be reported to the physician. This elevated temperature could indicate infection or another complication following the surgery. It is important for the physician to evaluate the child's condition and determine the appropriate course of action. Simply recording the temperature on nurses' notes or keeping the child warm with blankets is not adequate management in this situation. Applying a hypothermia blanket would also not be appropriate as the child is already febrile. The priority in this scenario is to report the findings to the physician for further assessment and intervention.

Correct Answer: C

Rationale: The best explanation for the patient is option C, which states, "The irrigation is needed to keep the catheter from becoming occluded by blood clots." After a transurethral resection of the prostate (TURP), it is common for the patient to have some bleeding in the bladder. Bladder irrigation is done to prevent blood clots from forming and blocking the catheter. Keeping the catheter patent is important to ensure proper drainage of urine and prevent complications such as urinary retention. While the other options are related to potential reasons for bladder irrigation, option C directly addresses the immediate concern of preventing catheter occlusion by blood clots post-TURP surgery.

Correct Answer: C

Rationale: Cloudy penile discharge is a common symptom of urethritis, which is inflammation of the urethra usually caused by an infection, such as a sexually transmitted infection (STI) like gonorrhea or chlamydia. Painful and frequent urination are also classic symptoms of urethritis. Painful urination, or dysuria, may occur due to the irritation and inflammation of the urethra. Frequency of urination can be a result of the body's response to the infection or inflammation. Therefore, assessing for these additional symptoms helps in confirming the diagnosis of urethritis and determining the appropriate treatment for the patient.

Correct Answer: A

Rationale: In a patient experiencing hemorrhage from multiple trauma sites leading to hypovolemia, compensatory mechanisms typically include an increase in heart rate (tachycardia), a decrease in urine output (oliguria), and an increase in respiratory rate (tachypnea). These mechanisms are the body's way of trying to maintain vital organ perfusion in the setting of decreased blood volume. However, hypertension is not typically seen in the setting of hypovolemia. In fact, blood pressure tends to decrease as a result of reduced circulating volume.

Correct Answer: C

Rationale: Comparing the patient's present weight with her last weight is the best way to quickly assess volume depletion in Miss CC. As she has been experiencing frequent diarrhea leading to blood and fluid loss, changes in weight are a reliable indicator of changes in the body's fluid status. A significant decrease in weight would suggest a loss of fluid and potential hypovolemia due to the diarrhea. This method is simple, immediate, and directly reflects the impact of the fluid loss on the body's volume status. Measuring the quantity and specific gravity of her urine output could provide information on her kidney function but may not be as quick and direct in evaluating volume depletion as comparing her current weight with her last recorded weight. Taking her blood pressure is important in assessing overall cardiovascular status but may not be as immediate in reflecting the impact of fluid loss on volume status. Administering the oral water test is not a standard method for quickly assessing volume depletion in this scenario.