NR325 EXAM 2 COMPLETE
QUESTIONS WITH CORRECT AND
OUTLINED ANSWERS
\Q\.The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia
who is receiving chemotherapy. The nurse notes that the client's platelet count is 20,000 mm3
(200 × 109/L). The nurse would prepare to implement which action based on this finding? -
ANSWER-✔A. Remove the fresh flowers from the client's room.
-----B. Remove the rectal thermometer from the client's room.
C. Instruct family members to wear a mask when entering the client's room.
D. Call the dietary department to report that the client will be on a low-bacteria diet.
When the client's platelet count is low, the client is at risk for bleeding. Options 1, 3, and 4
relate to the risk for infection. Rectal temperatures would not be taken on a client who is at risk
for bleeding because the thermometer could cause an alteration in the delicate rectal
membranes and lead to bleeding.
LOW PLATELETS RISK FOR BLEEDING
\Q\.The client diagnosed with benign prostatic hyperplasia (BPH) is scheduled for a transrectal
ultrasound examination and a test to measure the level of prostate-specific antigen (PSA). The
client says to the nurse, "I can't remember . . . can you tell me again why I need these tests to be
done?" The nurse responds, knowing that these tests are done for which purpose? - ANSWER-
✔A. To help predict the course of BPH
----B. Help to rule out the possibility of cancer
,C. Identify the likelihood of developing a urinary obstruction
D. Give an indication of whether intermittent self-catheterization is needed
A transrectal ultrasound examination and PSA level determination help to rule out the
possibility of prostate cancer. They do not specifically predict the course of BPH or the
development of complications such as urinary obstruction. These tests have nothing to do with
determining the need for self-catheterization.
\Q\.The nurse is monitoring a client who has just returned from surgery after a transurethral
resection of the prostate (TURP) to treat prostate cancer. The client has a three-way Foley
catheter in place for ongoing bladder irrigation. The nurse is observing the color of the client's
urine and would expect which urine color during the immediate postoperative period? -
ANSWER-✔----A. Pale pink urine
B. Dark pink urine
C. Tea-colored urine
D. Bright red blood with small clots in the urine
Rationale:If the bladder irrigation is infusing at a sufficient rate, the urinary drainage through
the Foley tubing would be pale pink. Additionally, no clots would be present.
Dark pink urine indicates that the rate of the irrigation solution needs to be increased.
Tea-colored urine is not seen after TURP but may be noted in a client with other renal disorders
such as renal failure.
Bright red bleeding and clots could indicate a complication, and if this is noted, it needs to be
reported to the primary health care provider.
\Q\.The nurse is planning teaching for a client diagnosed with chlamydia. Which information
would the nurse plan to include in the teaching session? - ANSWER-✔A. Alter the perineal pH by
using a spermicide with a condom.
----B. Keep follow-up appointments for repeat cultures
C. Discontinue antibiotics after 3 weeks of uninterrupted administration.
D. Identify sexual partners for the past 6 months so that they can be treated.
,Rationale:Follow-up cultures are typically done in 2-3 months to evaluate the effectiveness of
the medication. Using a spermicide does not change the perineal pH. The infection can be
prevented by the use of latex condoms. Chlamydial infection is treated with antibiotics
(azithromycin or doxycycline), which are not discontinued until the prescribed course is
completed. All sexual partners during the 30-60 days before diagnosis would be notified,
examined, and treated as necessary.
\Q\.A female client seen in the ambulatory care clinic has a history of syphilis infection. The
nurse assessing the client for reinfection would expect to observe a lesion on the labia that has
which characteristic? - ANSWER-✔---A. Is painless and indurated
B. Has a cauliflowerlike appearance
C. Is erythematous and papular in appearance
D. Appears as one or more vesicles that then rupture
Rationale:The characteristic lesion of syphilis is painless and indurated. The lesion is referred to
as a chancre. Genital warts are characterized by cauliflowerlike growths or growths that are soft
and fleshy. Scabies is characterized by erythematous, papular eruptions. Genital herpes is
accompanied by the presence of one or more vesicles that then rupture and heal.
\Q\.The client seen in the health care clinic has tested positive for gonorrhea. The nurse
anticipates that which medication will be prescribed based on this finding? - ANSWER-✔A.
Acyclovir
---B. Ceftriaxone
C. Metronidazole
D. Penicillin G benzathine
Rationale:Treatment for gonorrhea consists of antibiotic therapy, usually with ceftriaxone (or
azithromycin). Acyclovir is the treatment for genital herpes simplex virus; Metronidazole is the
treatment for a Trichomoniasis infection, and penicillin G benzathine is the treatment for syphili
, \Q\.After reviewing the electronic medical record shown in the accompanying figure for a client
who had transurethral resection of the prostate the previous day, which information requires
the most rapid action by the nurse - ANSWER-✔Bladder spasms and lack of urine output
indicate that the nurse needs to assess the continuous bladder irrigation for kinks and may need
to manually irrigate the client's catheter. The other information will also require actions, such as
having the client take deep breaths and cough and discussing the need for antihypertensive
medication prescriptions with the health care provider, but the nurse's first action should be to
address the problem with the urinary drainage system.
\Q\.A client has returned from a transurethral resection of the prostate with a continuous
bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots
are observed 5 hours after the surgery? - ANSWER-✔a. Review the hemoglobin and hematocrit
as ordered.
--b. Take vital signs and notify the surgeon immediately.
c. Release the traction on the three-way catheter.
d. Remind the client not to pull on the catheter.
Bright red urinary drainage with clots may indicate arterial bleeding. Vital signs would be taken
and the surgeon notified. The traction on the three-way catheter would not be released since it
places pressure at the surgical site to avoid bleeding. The nurse's review of hemoglobin and
hematocrit and reminding the client not to pull on the catheter are good choices, but not the
priority at this time.
\Q\.Which action will the nurse include in the plan of care for a client with right arm
lymphedema? - ANSWER-✔A. Avoid exercise on the right arm.
---B. Assist with application of a compression sleeve.
C. Keep the right arm at or below the level of the heart.
D. Check blood pressure (BP) on both right and left arms.
QUESTIONS WITH CORRECT AND
OUTLINED ANSWERS
\Q\.The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia
who is receiving chemotherapy. The nurse notes that the client's platelet count is 20,000 mm3
(200 × 109/L). The nurse would prepare to implement which action based on this finding? -
ANSWER-✔A. Remove the fresh flowers from the client's room.
-----B. Remove the rectal thermometer from the client's room.
C. Instruct family members to wear a mask when entering the client's room.
D. Call the dietary department to report that the client will be on a low-bacteria diet.
When the client's platelet count is low, the client is at risk for bleeding. Options 1, 3, and 4
relate to the risk for infection. Rectal temperatures would not be taken on a client who is at risk
for bleeding because the thermometer could cause an alteration in the delicate rectal
membranes and lead to bleeding.
LOW PLATELETS RISK FOR BLEEDING
\Q\.The client diagnosed with benign prostatic hyperplasia (BPH) is scheduled for a transrectal
ultrasound examination and a test to measure the level of prostate-specific antigen (PSA). The
client says to the nurse, "I can't remember . . . can you tell me again why I need these tests to be
done?" The nurse responds, knowing that these tests are done for which purpose? - ANSWER-
✔A. To help predict the course of BPH
----B. Help to rule out the possibility of cancer
,C. Identify the likelihood of developing a urinary obstruction
D. Give an indication of whether intermittent self-catheterization is needed
A transrectal ultrasound examination and PSA level determination help to rule out the
possibility of prostate cancer. They do not specifically predict the course of BPH or the
development of complications such as urinary obstruction. These tests have nothing to do with
determining the need for self-catheterization.
\Q\.The nurse is monitoring a client who has just returned from surgery after a transurethral
resection of the prostate (TURP) to treat prostate cancer. The client has a three-way Foley
catheter in place for ongoing bladder irrigation. The nurse is observing the color of the client's
urine and would expect which urine color during the immediate postoperative period? -
ANSWER-✔----A. Pale pink urine
B. Dark pink urine
C. Tea-colored urine
D. Bright red blood with small clots in the urine
Rationale:If the bladder irrigation is infusing at a sufficient rate, the urinary drainage through
the Foley tubing would be pale pink. Additionally, no clots would be present.
Dark pink urine indicates that the rate of the irrigation solution needs to be increased.
Tea-colored urine is not seen after TURP but may be noted in a client with other renal disorders
such as renal failure.
Bright red bleeding and clots could indicate a complication, and if this is noted, it needs to be
reported to the primary health care provider.
\Q\.The nurse is planning teaching for a client diagnosed with chlamydia. Which information
would the nurse plan to include in the teaching session? - ANSWER-✔A. Alter the perineal pH by
using a spermicide with a condom.
----B. Keep follow-up appointments for repeat cultures
C. Discontinue antibiotics after 3 weeks of uninterrupted administration.
D. Identify sexual partners for the past 6 months so that they can be treated.
,Rationale:Follow-up cultures are typically done in 2-3 months to evaluate the effectiveness of
the medication. Using a spermicide does not change the perineal pH. The infection can be
prevented by the use of latex condoms. Chlamydial infection is treated with antibiotics
(azithromycin or doxycycline), which are not discontinued until the prescribed course is
completed. All sexual partners during the 30-60 days before diagnosis would be notified,
examined, and treated as necessary.
\Q\.A female client seen in the ambulatory care clinic has a history of syphilis infection. The
nurse assessing the client for reinfection would expect to observe a lesion on the labia that has
which characteristic? - ANSWER-✔---A. Is painless and indurated
B. Has a cauliflowerlike appearance
C. Is erythematous and papular in appearance
D. Appears as one or more vesicles that then rupture
Rationale:The characteristic lesion of syphilis is painless and indurated. The lesion is referred to
as a chancre. Genital warts are characterized by cauliflowerlike growths or growths that are soft
and fleshy. Scabies is characterized by erythematous, papular eruptions. Genital herpes is
accompanied by the presence of one or more vesicles that then rupture and heal.
\Q\.The client seen in the health care clinic has tested positive for gonorrhea. The nurse
anticipates that which medication will be prescribed based on this finding? - ANSWER-✔A.
Acyclovir
---B. Ceftriaxone
C. Metronidazole
D. Penicillin G benzathine
Rationale:Treatment for gonorrhea consists of antibiotic therapy, usually with ceftriaxone (or
azithromycin). Acyclovir is the treatment for genital herpes simplex virus; Metronidazole is the
treatment for a Trichomoniasis infection, and penicillin G benzathine is the treatment for syphili
, \Q\.After reviewing the electronic medical record shown in the accompanying figure for a client
who had transurethral resection of the prostate the previous day, which information requires
the most rapid action by the nurse - ANSWER-✔Bladder spasms and lack of urine output
indicate that the nurse needs to assess the continuous bladder irrigation for kinks and may need
to manually irrigate the client's catheter. The other information will also require actions, such as
having the client take deep breaths and cough and discussing the need for antihypertensive
medication prescriptions with the health care provider, but the nurse's first action should be to
address the problem with the urinary drainage system.
\Q\.A client has returned from a transurethral resection of the prostate with a continuous
bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots
are observed 5 hours after the surgery? - ANSWER-✔a. Review the hemoglobin and hematocrit
as ordered.
--b. Take vital signs and notify the surgeon immediately.
c. Release the traction on the three-way catheter.
d. Remind the client not to pull on the catheter.
Bright red urinary drainage with clots may indicate arterial bleeding. Vital signs would be taken
and the surgeon notified. The traction on the three-way catheter would not be released since it
places pressure at the surgical site to avoid bleeding. The nurse's review of hemoglobin and
hematocrit and reminding the client not to pull on the catheter are good choices, but not the
priority at this time.
\Q\.Which action will the nurse include in the plan of care for a client with right arm
lymphedema? - ANSWER-✔A. Avoid exercise on the right arm.
---B. Assist with application of a compression sleeve.
C. Keep the right arm at or below the level of the heart.
D. Check blood pressure (BP) on both right and left arms.
