Test Bank Pharmacology and the Nursing Process

Correct Answer: A

Rationale: The correct answer is A: after the surgery, bleeding is normal. This is because after a TURP procedure, it is common for some bleeding to occur, leading to blood clots in the urine bag. The surgical site undergoes trauma, causing bleeding as a part of the healing process. Choice B is incorrect because while irrigation may be done post-surgery, blood clots in the urine bag are expected due to the surgery itself, not just irrigation. Choice C is incorrect as it is normal for some bleeding to occur after TURP, and immediate physician intervention is not necessary unless excessive bleeding is observed. Choice D is incorrect as tugging on the catheter may cause bleeding, but in this case, the presence of blood clots is likely due to the surgery itself, not catheter irritation.

Correct Answer: A

Rationale: Step 1: Vitamin K is essential for the synthesis of clotting factors in the liver. Step 2: A splenectomy increases the risk of bleeding due to decreased platelet sequestration. Step 3: Preoperative Vitamin K injection helps correct any clotting deficiencies. Summary: - Choice B is incorrect as Vitamin K does not prevent infection. - Choice C is incorrect as Vitamin K does not directly promote healing. - Choice D is incorrect as Vitamin K does not dry secretions.

Correct Answer: C

Rationale: The correct answer is C: Use the smallest needle possible for injections. In a client with thrombocytopenia (low platelet count), there is an increased risk of bleeding and bruising. Using the smallest needle possible for injections reduces the risk of causing injury to blood vessels and tissues, minimizing bleeding complications. Limiting visits by family members (choice A) is not directly related to protecting the client's safety. Encouraging wheelchair use (choice B) is not necessary unless indicated for mobility reasons. Maintaining accurate fluid intake and output records (choice D) is important for overall client care but does not directly address the risk of bleeding in thrombocytopenia.

Correct Answer: B

Rationale: The correct answer is B because a saturated and leaking dressing indicates a potential infection risk and compromised wound healing. The nurse should revise the plan of care and change the dressing immediately to prevent complications. Waiting until 1800 (choice A) could lead to further contamination and delay in treatment. Reassessing in 2 hours (choice C) might worsen the condition. Discontinuing the plan of care (choice D) is not appropriate without addressing the immediate issue.

Correct Answer: C

Rationale: The correct answer is C: platelets 18,000. A critically low platelet count can lead to life-threatening bleeding in the ICU. Normal platelet count ranges from 150,000 to 450,000. A count of 18,000 indicates severe thrombocytopenia. Immediate reporting is crucial for prompt intervention. Rationale for why other choices are incorrect: A: Hematocrit of 48% is within normal range (male: 42-52%, female: 37-47%). B: paCO2 of 38 mm Hg is within normal range (35-45 mm Hg). D: WBC count of 8000 is within normal range (4000-11000/uL). In critical care settings, it is vital to prioritize and address life-threatening conditions promptly, hence the urgent need to report the critically low platelet count.