A bed-bound chart has a prescription for routine urinalysis. In which way does the nurse obtain the urine sample for the laboratory?

Insert an indwelling urinary catheter

Insert an intermittent urinary catheter

Cleanse the urinary meatus and provide a sterile container

Pour urine collected from a clean bedpan into a specimen cup

Answer and Explanation

The Correct Answer is C

This is known as a clean-catch urine sample. The nurse cleanses the urinary meatus to reduce the chance of contamination from bacteria on the skin. The patient then collects a urine sample in a sterile container while voiding.

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Correct Answer is A

Explanation

This is because the outcome of the plan is for the client to learn self-glucose testing, which implies that the client can perform the testing correctly on their own. Option A shows that the client has successfully learned and can perform the skill independently, which is the ultimate goal of the plan.

Option B, "Client says 'I can do the testing now'," and option C, "Client explains the testing process to the nurse," may show that the client has some understanding of the testing process, but they do not demonstrate that the client can perform the skill independently.

Option D, "Client observes the nurse test glucose 5 times," is not an appropriate method for evaluating the client's ability to perform self-glucose testing. Observing the nurse perform the skill does not demonstrate that the client has learned the skill themselves.

A. Places the client in Trendelenburg position B. Stays with the client and calls for assistance C. Place sterile moistened ABD pads over the wound D. With a sterile glove, attempts to reinsert the intestine into the abdominal cavity E. Encourages the client to drink ﬂuids F. Obtains the client's vital signs

Correct Answer is ["B","C"]

Explanation

The client has a complication of the surgical wound dehiscence, which occurs when the wound edges separate or pull apart. In this case, a portion of the intestine is protruding from the wound bed, indicating a wound evisceration. It is a medical emergency that requires prompt intervention to prevent complications such as infection, hemorrhage, or sepsis.

The nurse should first stay with the client and call for assistance to notify the healthcare provider or surgical team immediately. The surgical team will need to evaluate the wound and perform emergency surgery if necessary.

The nurse should then place sterile moistened ABD pads over the wound to prevent the intestine from drying out and to protect the protruding tissue from further injury or infection.

Placing the client in Trendelenburg position (a) is contraindicated as it can cause a shift of abdominal contents and further worsen the condition. Attempting to reinsert the intestine into the abdominal cavity (d) is also not within the scope of practice for the nurse and can cause harm to the client. Encouraging the client to drink ﬂuids (e) or obtaining the client's vital signs (f) are not the priority actions in this situation.

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A bed-bound chart has a prescription for routine urinalysis. In which way does the nurse obtain the urine sample for the laboratory?

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Naxlex Comprehensive Predictor Exams

The nurse evaluates a client's plan of care. The client has an outcome of 'Client will learn self-glucose testing before discharge'. When evidence best allows the nurse to meet the outcome of the plan?

Correct Answer is A

Explanation

Correct Answer is ["B","C"]

Explanation

The nurse omits to document an assessment finding that resulted in a significant client injury. For which legal issue does the nurse need to prepare?

The nurse plans care for a client who reports avoiding people because of having scabies and difficulty walking. Which statement does the nurse document as the client's greatest concern?

The nurse provides care for a patient with an infected surgical wound. The nurse assesses the wound and changes the dressing. Which does the nurse include in the documentation? Select all that apply.

The nurse provides care for a client recovering from a motor vehicle crash. For which sign of ﬂuid volume overload does the nurse measure the client's intake and output? (Select all that apply)

The nurse provides care for a client who is severely malnourished. A central venous access device (CVAD) is placed to administer total parenteral nutrition (TPN). Which laboratory result does the nurse closely monitor?

A client diagnosed with a bilateral hearing impairment seeks medical attention for an acute health problem. Which approach does the nurse use to enhance communication with this client?

The nurse provides care for a client having an incisional biopsy of a skin lesion. Which teaching about the care of the site does the nurse provide to the client?