A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first?
Schedule for IVP.
Draw blood for blood urea nitrogen (BUN) and creatinine.
Insert 16 French retention catheter.
Administer lorazepam (Ativan) 0.5 mg.
The Correct Answer is C
The nurse should act on the order to insert a 16 French retention catheter first. The patient's markedly distended bladder and agitated and confused state suggest acute urinary retention, which can be relieved by inserting a catheter to drain the urine. This is a priority intervention as urinary retention can lead to serious complications such as bladder rupture, hydronephrosis, and renal failure. Once the catheter is inserted and the patient's bladder is drained, the healthcare provider can order further tests such as an IVP or blood tests to assess renal function. The order for lorazepam can be addressed after the catheter is inserted and the patient's urinary retention is addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement is correct. Impaired fasting glucose (IFG) is a condition in which the fasting blood glucose level is higher than normal but not high enough to be diagnosed as diabetes. However, people with IFG are at increased risk of developing type 2 diabetes and cardiovascular disease. Weight loss and exercise can help to prevent or delay the onset of diabetes and reduce the risk of cardiovascular disease.
Correct Answer is B
Explanation
Counting sponges, needles, and surgical instruments is an intraoperative activity that is specific to the circulating function of the perioperative nurse. The nurse is responsible for maintaining an accurate count of all surgical items to prevent leaving any foreign objects inside the patient after the surgery. This is a crucial task to ensure patient safety and prevent any potential complications that may arise from such errors.
Option a. admitting, identifying, and assessing the patient, is a preoperative function that is usually performed by the preoperative nurse.
Option c. passing instruments to the surgeon and assistants, is a scrub nurse function that requires knowledge of the surgical procedure and a sterile technique.
Option d. preparing the instrument table and sterile equipment is also a scrub nurse function that requires expertise in sterile technique, knowledge of surgical procedures, and the ability to maintain a sterile environment.
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