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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

NSAIDs are known to be a common cause of acute gastritis. Therefore, it is essential for the nurse to ask the patient about their frequency of NSAID use to determine if this may have caused their current symptoms. Other options such as family history of gastric problems, recent weight gain or loss, and amount of fat in the diet, may also be relevant to the patient's overall health status, but they are not as important as the potential cause of their current condition.

A. Electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia. B. The presence of hypovolemic shock related to osmotic diuresis. C. Cardiovascular collapse resulting from the eﬀects of hyperglycemia. D. Fluid overload resulting from aggressive ﬂuid replacement.

Correct Answer is A

Explanation

Electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia are the main reasons for initiating cardiac monitoring in patients with diabetic ketoacidosis. In diabetic ketoacidosis, insulin deficiency causes the body to break down fat for energy, leading to the production of ketones and resulting in metabolic acidosis. In addition, glucose and potassium are lost in the urine due to osmotic diuresis. Hypokalemia can cause ECG changes and dysrhythmias, which can be life-threatening.

Hypokalemia is a common complication of DKA and can lead to ECG changes such as ST-segment depression, T-wave inversion, and U waves².

Hypovolemic shock related to osmotic diuresis is an important consideration in the management of diabetic ketoacidosis, but it is not the primary reason for initiating cardiac monitoring.

Cardiovascular collapse resulting from the eﬀects of hyperglycemia is not a common complication of diabetic ketoacidosis, and it is not the primary reason for initiating cardiac monitoring.

Fluid overload resulting from aggressive ﬂuid replacement is a potential complication of diabetic ketoacidosis, but it is not the primary reason for initiating cardiac monitoring.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a patient who is nauseated and vomiting up blood-streaked ﬂuid with diagnosis of acute gastritis. When obtaining the admission health history, it will be most important for the nurse to ask the patient about:

Correct Answer is A

Explanation

Cardiac monitoring is initiated for a patient with diabetic ketoacidosis. The nurse determines that this measure is important to identify:

Correct Answer is A

Explanation

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