MS4 ACTUAL EXAM QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS VERIFIED LATEST UPDATE
After transurethral resection of the prostate, the nurse notices that the urine
draining from the catheter is bright red, has numerous clots, and is viscous.
Which nursing action is most appropriate?
Assess vital signs and notify the surgeon.
Explanation:
Blood clots are normal after transurethral resection of the prostate, but bright red urine
can indicate a hemorrhage. The nurse should assess the client's vital signs and notify
the surgeon. Irrigation of the catheter may help remove clots, but it does not decrease
bleeding. Milking a urinary catheter or increasing fluid intake is not effective for
controlling bleeding or decreasing clots.
A client reports having difficulty voiding to the nurse. What question(s) will the
nurse ask the client? Select all that apply.
"Are you waking up in the middle of the night to void?"
"How much fluids are you drinking in the late evenings?"
"What are your usual voiding patterns?"
,Explanation:
The nurse will focus on the genitourinary system with voiding during the night, drinking
fluids in the evening, and patterns of voiding. The history of hemorrhoids and the
colonoscopy are related to the gastrointestinal system.
The nurse teaches a female client who has cystitis methods to relieve discomfort
until the antibiotic takes effect. Which response by the client would indicate that
they understand the nurse's instructions?
"I will:
Strain the urine carefully.
Explanation:
Intermittent pain that is less colicky indicates that the calculi may be moving along the
urinary tract. Fluids should be encouraged to promote movement, and the urine should
be strained to detect the passage of the stone. Hematuria is to be expected from the
irritation of the stone. Analgesics should be administered when the client needs them,
not routinely. Moist heat to the flank area is helpful when renal colic occurs, but it is less
necessary as pain is lessened.
The nurse teaches a female client who has cystitis methods to relieve discomfort
until the antibiotic takes effect. Which response by the client would indicate that
they understand the nurse's instructions?
"I will:
take warm tub baths."
, Explanation:
Warm tub baths promote relaxation and help relieve urgency, discomfort, and spasm.
Applying heat to the perineum is more helpful than cold because heat reduces
inflammation. Although liberal fluid intake should be encouraged, caffeinated
beverages, such as tea, coffee, and cola, can be irritating to the bladder and should be
avoided. Voiding at least every 2 to 3 hours should be encouraged because it reduces
urinary stasis.
A nurse is instructing a client with an ileal conduit about skin care around the
stoma. What should the nurse tell the client about stoma care? Select all that
apply.
"The stoma will shrink to a normal size in 4 to 6 weeks."
"You can take a shower or a bath with the appliance on or off."
"You can use an electric razor to remove the hair around the stoma."
Explanation:
The nurse should instruct the client with an ileal conduit that the stoma will shrink in
about 4 to 6 weeks. The client can take a shower or a bath with the collection pouch on
or off. The client can shave the hair around the stoma using an electric razor to make it
easier for the collection bag to adhere to the skin. The client should wash the skin
around the stoma with water; it is not necessary to use an antibacterial soap, and soap
COMPLETE SOLUTIONS VERIFIED LATEST UPDATE
After transurethral resection of the prostate, the nurse notices that the urine
draining from the catheter is bright red, has numerous clots, and is viscous.
Which nursing action is most appropriate?
Assess vital signs and notify the surgeon.
Explanation:
Blood clots are normal after transurethral resection of the prostate, but bright red urine
can indicate a hemorrhage. The nurse should assess the client's vital signs and notify
the surgeon. Irrigation of the catheter may help remove clots, but it does not decrease
bleeding. Milking a urinary catheter or increasing fluid intake is not effective for
controlling bleeding or decreasing clots.
A client reports having difficulty voiding to the nurse. What question(s) will the
nurse ask the client? Select all that apply.
"Are you waking up in the middle of the night to void?"
"How much fluids are you drinking in the late evenings?"
"What are your usual voiding patterns?"
,Explanation:
The nurse will focus on the genitourinary system with voiding during the night, drinking
fluids in the evening, and patterns of voiding. The history of hemorrhoids and the
colonoscopy are related to the gastrointestinal system.
The nurse teaches a female client who has cystitis methods to relieve discomfort
until the antibiotic takes effect. Which response by the client would indicate that
they understand the nurse's instructions?
"I will:
Strain the urine carefully.
Explanation:
Intermittent pain that is less colicky indicates that the calculi may be moving along the
urinary tract. Fluids should be encouraged to promote movement, and the urine should
be strained to detect the passage of the stone. Hematuria is to be expected from the
irritation of the stone. Analgesics should be administered when the client needs them,
not routinely. Moist heat to the flank area is helpful when renal colic occurs, but it is less
necessary as pain is lessened.
The nurse teaches a female client who has cystitis methods to relieve discomfort
until the antibiotic takes effect. Which response by the client would indicate that
they understand the nurse's instructions?
"I will:
take warm tub baths."
, Explanation:
Warm tub baths promote relaxation and help relieve urgency, discomfort, and spasm.
Applying heat to the perineum is more helpful than cold because heat reduces
inflammation. Although liberal fluid intake should be encouraged, caffeinated
beverages, such as tea, coffee, and cola, can be irritating to the bladder and should be
avoided. Voiding at least every 2 to 3 hours should be encouraged because it reduces
urinary stasis.
A nurse is instructing a client with an ileal conduit about skin care around the
stoma. What should the nurse tell the client about stoma care? Select all that
apply.
"The stoma will shrink to a normal size in 4 to 6 weeks."
"You can take a shower or a bath with the appliance on or off."
"You can use an electric razor to remove the hair around the stoma."
Explanation:
The nurse should instruct the client with an ileal conduit that the stoma will shrink in
about 4 to 6 weeks. The client can take a shower or a bath with the collection pouch on
or off. The client can shave the hair around the stoma using an electric razor to make it
easier for the collection bag to adhere to the skin. The client should wash the skin
around the stoma with water; it is not necessary to use an antibacterial soap, and soap
