Yesterday, a male client had a transurethral resection of the prostate (TURP). Today, the client is concerned about the small amount of blood found in his urine. The nurse should explain to the client that the blood:

Correct Answer: C

Rationale: Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. The client will continue to have a small amount of hematuria even after the Foley catheter is removed. Some hematuria is usual for several days after surgery. The client should not be concerned, unless the amount increases. Irrigating the bladder will not remove the hematuria. Irrigation is performed to remove blood clots and to facilitate urinary drainage.

Correct Answer: A

Rationale: Many physicians do not use the internal mammary artery because it is time consuming. Removing the internal mammary artery does not pose a greater risk of reocclusion. In fact, it may stay patent longer. The internal mammary artery is larger in diameter than the saphenous vein. The internal mammary artery does not have too many valves.

Correct Answer: B

Rationale: In this scenario, the correct order to assess patients is as follows: 1. **B) An irritable infant with a fever, petechiae, and nuchal rigidity** - This patient presents with signs and symptoms that are concerning for meningitis, a serious and potentially life-threatening condition. Prompt assessment and intervention are crucial in this situation to prevent complications. 2. **C) A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity** - This patient's condition, a twisted ankle with intact pedal pulse and no deformity, is a less urgent situation compared to the infant with suspected meningitis. While still important, this patient can be assessed after addressing the more critical cases. 3. **D) A 50-year-old female with moderate abdominal pain and occasional vomiting** - Abdominal pain and vomiting can indicate various conditions, some of which may require immediate attention. However, they are generally not as time-sensitive as a potential case of meningitis in an infant. 4. **A) An ambulatory, dazed 25-year-old male with a bandaged head wound** - While head injuries should always be taken seriously, in this case, the patient is ambulatory and dazed, indicating a less severe presentation compared to the other scenarios. This patient can be assessed after addressing the more urgent cases. Educational Context: This question assesses the prioritization of patient assessment based on the severity and urgency of their conditions. Understanding the principles of triage and prioritization in healthcare is essential for healthcare providers to deliver safe and effective care. By correctly identifying the most critical patient in need of immediate assessment and intervention, healthcare professionals can optimize patient outcomes and provide timely care to those who need it most.

Correct Answer: A

Rationale: In the context of adult medical-surgical care, delegating tasks to nursing staff should align with their scope of practice and level of training. The appropriate task to delegate to a nursing assistant in this scenario is chest compressions (Option A). Nursing assistants are often trained in basic life support (BLS) which includes performing chest compressions during cardiopulmonary resuscitation (CPR). This task is within their skill set and responsibilities. Options B, C, and D involve more advanced skills that require specialized training and knowledge beyond what a nursing assistant typically possesses. Bag-valve mask ventilation (Option B), assisting with oral intubation (Option C), and placing defibrillator pads (Option D) are tasks that should be performed by licensed healthcare providers such as registered nurses or respiratory therapists who have the required expertise and training. Educationally, understanding the principles of delegation is crucial for nurses and nursing assistants to provide safe and effective patient care. Nurses must assess the competency of staff members before delegating tasks to ensure that the right task is assigned to the right person. This promotes patient safety, optimizes workflow, and enhances teamwork within the healthcare team. By knowing the scope of practice for different healthcare roles, nurses can delegate tasks appropriately, maximizing efficiency and quality of care.

Correct Answer: C

Rationale: In the context of adult medical-surgical care, the correct task to delegate to the LPN/LVN among the options provided is to wrap the amputated digits in sterile gauze moistened with saline (Option C). This task falls within the scope of practice for an LPN/LVN and aligns with principles of wound care and infection control. Option A, cleansing the amputated digits with Betadine solution, may require a higher level of assessment and decision-making, making it more appropriate for a registered nurse (RN) or above. Option B, placing the amputated digits directly into ice slurry, can potentially cause tissue damage due to extreme cold and is not recommended. Option D, storing the amputated digits in a solution of sterile normal saline, is not as appropriate as wrapping the digits in moistened gauze, which helps maintain tissue hydration and minimizes bacterial contamination. In an educational context, understanding delegation principles is crucial for nursing practice. LPNs/LVNs should be assigned tasks that align with their scope of practice and competency level, ensuring safe and effective patient care. Proper wound care techniques, such as moistening gauze with saline for amputated digits, contribute to optimal patient outcomes and prevent complications like infection. This rationale highlights the importance of delegation based on knowledge, skill level, and patient needs in the adult medical-surgical setting.