334 Final exam review

A patient has just undergone a Transurethral Resection of the Prostate (TURP). What is the nurse’s priority intervention in the immediate postoperative period?

• Ambulate the patient to prevent blood clots

• Monitor continuous bladder irrigation for clots and assess for bleeding

• Encourage fluid restriction to prevent bladder distention

• Discontinue urinary catheter within 12 hours post-op

Answer explanation

The priority intervention after TURP is to monitor continuous bladder irrigation for clots and assess for bleeding, as this helps prevent complications such as hemorrhage and ensures proper bladder function.

Which risk factors are part of the prenatal stage for cerebral palsy? Select all that apply.

• Infections and malnutrition

• Bleeding in placenta

• Sepsis/preeclampsia

• Cerebral infections and head injury

• Prolonged labor or premature births

Answer explanation

Infections and malnutrition, along with bleeding in the placenta, are significant prenatal risk factors for cerebral palsy. They can adversely affect fetal development, increasing the likelihood of this condition.

What describes the therapeutic effect of baclofen in CP?

• Decreases muscle spasms as a skeletal muscle relaxant

• IM injection that inhibits acetylcholine release for reduction of spasticity in specific muscle groups

• Inhibits seizure activity

• Pump inserted underneath the abdominal skin that centrally reduces skeletal muscle spasms and spasticity

Answer explanation

Baclofen is delivered via a pump inserted under the abdominal skin, providing targeted relief from muscle spasms and spasticity in cerebral palsy, making it effective for managing these symptoms centrally.

What manifestations are expected in a patient with Parkinson's disease?

• Pill-rolling tremor

• Shuffling gait

• Stiffness

• Severe headaches

• Seizures

Answer explanation

In Parkinson's disease, common manifestations include a pill-rolling tremor, shuffling gait, and stiffness. Severe headaches and seizures are not typical symptoms of this condition.

A nurse assesses a patient with an acute asthma attack. Which of the following findings indicates severely compromised gas exchange?

• Loud expiratory wheezes

• SpO2 of 96% on RA

• Silent chest

• Productive cough with clear sputum

Answer explanation

A 'silent chest' indicates severely compromised gas exchange in asthma, as it suggests minimal airflow and lack of wheezing, which can be life-threatening. Other options indicate varying degrees of airflow but not severe compromise.

The nurse is assessing a client with suspected fluid volume excess. Which clinical findings support this diagnosis?

• Crackles in lungs

• Flat neck veins

• Weight gain of 3 lbs. in 24 hrs

• Bounding peripheral pulses

Answer explanation

Crackles in the lungs indicate fluid in the alveoli, supporting fluid volume excess. Flat neck veins suggest dehydration, not excess. Weight gain and bounding pulses also indicate fluid overload, but flat neck veins do not.

A client undergoing surgery under general anesthesia suddenly develops muscle rigidity, tachycardia, and an elevated body temperature. Which of the following actions should the nurse take first?

• Apply a cooling blanket and ice packs to the client

• Administer IV dopamine

• Stop the procedure and administer IV dantrolene

• Insert a urinary catheter to monitor output

Answer explanation

The client exhibits signs of malignant hyperthermia, a life-threatening condition. Administering IV dantrolene is the first priority to reverse the muscle rigidity and prevent further complications.

Select all risk factors for pulmonary embolism.

• Immobility

• Use of oral contraceptives

• Obesity

• Decreased platelet count

• Long bone fractures

Answer explanation

Risk factors for pulmonary embolism include immobility, use of oral contraceptives, obesity, and long bone fractures, as they can lead to venous thromboembolism. Decreased platelet count is not a risk factor.

Which of the following is most likely responsible for an embolic stroke in a patient with a history of atrial fibrillation? 

• A. Hypertension

• B. Hyperlipidemia

• C. Atrial fibrillation

• D. Diabetes Mellitus

Answer explanation

Atrial fibrillation leads to the formation of blood clots in the heart, which can travel to the brain and cause an embolic stroke. Therefore, in a patient with a history of atrial fibrillation, it is the most likely cause.

Which of the following do you expect to find as manifestations of peripheral artery disease?

• numbness/burning in feet

• capillary refill increases

• hot and swollen lower extremity

• bruit over femoral and aortic arteries

• cold and cyanotic extremity

Answer explanation

Peripheral artery disease can cause numbness/burning in feet, increased capillary refill time, and cold, cyanotic extremities due to reduced blood flow. Bruits indicate turbulent blood flow in narrowed arteries.