Question

A nurse is caring for a postoperative client following a perineal prostatectomy.

Answer 1

Correct Answers

Apply warm compresses to the incision site. [ Anticipated ]
Maintain bed rest for 2 days postoperatively. [ Contraindicated ]
Irrigate indwelling urinary catheter with 50 mL of normal saline. [ Contraindicated ]
Administer enema to relieve constipation. [ Contraindicated ]

Rationale :

🩺Applying warm compresses is an anticipated intervention as it helps reduce localized swelling and promote comfort at the surgical site following a perineal prostatectomy.

🚫Maintaining bed rest for 2 days is contraindicated because early ambulation reduces the risk of thromboembolism and pulmonary complications.

💉Irrigating the catheter without specific provider orders is contraindicated due to the risk of introducing pathogens and disrupting healing at the surgical site.

🚽Administering an enema is contraindicated because increased intra-abdominal pressure from straining may lead to bleeding or trauma near the prostatectomy site.

🛏️Placing a blanket roll under the knees should be avoided, as it can impair venous return and increase the risk of deep vein thrombosis.

Hint:

📌Core Message

Use warm compresses to reduce swelling and pain; avoid prolonged bed rest, catheter irrigation, rectal procedures, and knee flexion post-prostatectomy.

Answer 2

Correct Answers

Stay with the client for the first 15 min of the transfusion. [ Indicated ]
Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg. [ Not indicated ]
Document the blood product transfusion in the client's medical record. [ Indicated ]
Obtain the first unit of packed RBCs from the blood bank. [ Indicated ]
Start an IV bolus of lactated Ringer's solution. [ Not indicated ]

Rationale :

🩸Staying with the client during the first 15 minutes is essential because most transfusion reactions occur early, requiring prompt assessment.

📝Documenting transfusions ensures continuity of care, legal compliance, and tracking of potential adverse reactions.

🏥Obtaining RBCs from the blood bank is an anticipated preparation step before initiating the transfusion.

⚠️Titrating infusion rates to maintain a specific blood pressure target is not indicated without provider orders, especially in a client who is hypotensive and anemic—this could risk fluid overload.

🚫Lactated Ringer’s solution is contraindicated during blood transfusions due to its calcium content, which can cause clotting or hemolysis of the blood product.

📌Core Message

During blood transfusions, monitor closely at initiation, ensure proper documentation, and avoid using incompatible IV fluids or adjusting rate without orders.

Answer 3

Correct Answers

Insert an indwelling urinary catheter. [ Anticipated ]
Insert a nasogastric tube and maintain low intermittent suction. [ Anticipated ]
Administer lactated Ringer’s 1 L via IV bolus. [ Anticipated ]
Administer famotidine 20 mg via intermittent IV infusion twice daily. [ Anticipated ]

Rationale :

🧪Urinary catheterization is expected to track fluid balance in acute pancreatitis, especially with signs of hypovolemia and hemoconcentration.

🧼Nasogastric decompression reduces pancreatic stimulation, alleviates nausea/vomiting, and prevents aspiration in clients with severe abdominal distention.

💧Lactated Ringer’s solution is used for volume resuscitation in pancreatitis due to fluid losses into the third space and hypotension.

💊Famotidine helps suppress gastric acid secretion, protecting the gastric mucosa during critical illness and reducing risks of ulceration.

📌Core Message

In acute pancreatitis, initiate fluid resuscitation, gastric decompression, acid suppression, and monitor urine output.

Answer 4

Correct Answers:

Isolate the client from staff who are pregnant.

Rationale :

🛑Rubella (German measles) is a contagious viral infection that poses a severe risk to pregnant individuals, potentially causing congenital rubella syndrome in the fetus.

👩‍⚕️Pregnant staff should avoid contact with infected clients to prevent transplacental transmission.

🚫Aspirin is contraindicated in children and adolescents with viral infections due to risk of Reye's syndrome.

🌫️Airborne precautions are not required; rubella is transmitted via droplets, not airborne particles.

👄Koplik spots are associated with measles, not rubella.

📌Core Message

Rubella precautions involve protecting pregnant staff due to risk of congenital complications; avoid aspirin and distinguish from measles.

Answer 5

Correct Answers:

Remove the cap and place it sterile-side up on a clean surface.

Rationale :

🧴Maintaining sterility is crucial when handling sterile solution caps; placing the cap sterile-side up on a clean surface preserves its sterility for recapping.

💧Pouring solutions over the center of a sterile field increases the risk of fluid contamination—this must be avoided.

🔄The bottle label should face the palm to protect the label and reduce spillage risk, not facing outward.

🩹Spilled fluids on the sterile field compromise the field entirely, and covering it with gauze does not maintain sterility. A new sterile setup is required.

📌Core Message

Maintain sterility by placing solution caps sterile-side up; never pour fluids directly over the center of the sterile field.

Answer 6

Correct Answers:

Identify possible precipitating factors related to the infections.

Rationale :

🔍Root cause analysis is the essential first step in addressing a rise in infection rates, helping pinpoint the specific failures or patterns.

📊Interventions like staff education or policy revision should follow, based on the identified causes, not precede them.

🤝Meeting with providers is important, but more effective when evidence-based data on causative factors are available.

📋Revising policies without understanding the origin of the problem may lead to ineffective or misdirected changes.

📌Core Message

First identify infection causes before implementing training or policy changes to ensure targeted interventions.

Answer 7

Correct Answers:

administer sublingual nitroglycerin

Rationale :

❤️Nitroglycerin provides rapid vasodilation, relieving myocardial ischemia by improving oxygen delivery to cardiac tissue.

🧪Troponin levels may not rise immediately, so waiting for lab confirmation delays urgent care.

💊Beta-blockers, while useful later, do not offer immediate symptom relief during acute pain episodes.

📞Notifying a supervisor does not address the urgent need for symptom management and myocardial protection.

📌Core Message

In acute chest pain, prioritize rapid symptom relief using nitroglycerin before diagnostic or secondary treatments.

Answer 8

Correct Answers:

Administering potassium via IV bolus.

Rationale :

⚠️IV bolus potassium can cause fatal arrhythmias due to rapid serum potassium spikes—it violates safe medication administration standards.

📛This constitutes malpractice because it shows a reckless disregard for safety, potentially resulting in serious harm.

✅Placing fall risk bands and documenting provider communication are correct nursing actions and do not represent negligence.

🚫While clamping an NG tube could be a mistake, it only becomes malpractice if harm occurs and the nurse’s actions significantly deviate from standard care.

📌Core Message

Giving potassium as an IV bolus is unsafe and meets the criteria for malpractice due to its high risk of fatal complications.

Answer 9

Correct Answers:

Increase exercise.

Rationale :

🏃‍♀️Exercise stimulates bowel motility, which helps counteract opioid-induced constipation—a frequent side effect in clients with chronic pain.

💧Dehydration and low fiber intake worsen constipation; patients should maintain adequate hydration and fiber.

🚫Routine laxative use can lead to dependency and electrolyte imbalance, making it inappropriate as first-line prevention.

🌾Reducing insoluble fiber would have the opposite effect, further impairing stool passage.

📌Core Message

Encourage regular exercise to help manage opioid-related constipation in clients with chronic pain.

Answer 10

Correct Answers:

Ensure the state health department has been notified.

Rationale :

🦠Lyme disease is a reportable condition in many states, requiring notification to track public health trends and outbreaks.

🚫Antitoxin is not used in treating Lyme disease, which is bacterial, not toxin-based.

👚Personal item sharing is irrelevant, as Lyme disease is not spread person-to-person, but via tick bites.

🧬Skin necrosis is not typical of Lyme disease; the hallmark is erythema migrans, a distinctive rash.

📌Core Message

Report Lyme disease to public health authorities for epidemiological monitoring and disease control.

Option	Anticipated	Contraindicated
Apply warm compresses to the incision site.
Maintain bed rest for 2 days postoperatively.
Irrigate indwelling urinary catheter with 50 mL of normal saline.
Administer enema to relieve constipation.
Place a blanket roll under the client’s knees while in bed.

Option	Indicated	Not indicated
Stay with the client for the first 15 min of the transfusion.
Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
Document the blood product transfusion in the client's medical record.
Obtain the first unit of packed RBCs from the blood bank.
Start an IV bolus of lactated Ringer's solution.

Option	Anticipated	Contraindicated
Insert an indwelling urinary catheter.
Insert a nasogastric tube and maintain low intermittent suction.
Administer lactated Ringer’s 1 L via IV bolus.
Administer famotidine 20 mg via intermittent IV infusion twice daily.

1 :
A nurse is caring for a postoperative client following a perineal prostatectomy.

Correct Answers

2 :
The nurse reviews the entries in the medical record.

Correct Answers

3 :
A nurse in an emergency department is caring for a client.

Correct Answers

4 :
A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?

5 :
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

6 :
A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

8 :
A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

9 :
A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

10 :
A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?

1 : A nurse is caring for a postoperative client following a perineal prostatectomy.

Correct Answers

2 : The nurse reviews the entries in the medical record.

Correct Answers

3 : A nurse in an emergency department is caring for a client. ​​​​​​

Correct Answers

4 : A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?

5 : A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

6 : A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

8 : A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

9 : A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

10 : A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?

1 :
A nurse is caring for a postoperative client following a perineal prostatectomy.

2 :
The nurse reviews the entries in the medical record.

3 :
A nurse in an emergency department is caring for a client.

4 :
A nurse is admitting an adolescent who has rubella. Which of the following actions should the nurse take?

5 :
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

6 :
A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first?

8 :
A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

9 :
A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

10 :
A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?