A client who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?

Insert a foley catheter.

Schedule a pelvic magnetic resonance imaging test.

Infuse normal saline at 50 ml/hr.

Draw blood for a complete blood count.

Answer and Explanation

The Correct Answer is A

A. The primary concern in this scenario is urinary retention, which can lead to kidney dysfunction (indicated by elevated BUN and creatinine). The priority intervention is relieving the retention by inserting a Foley catheter, which will help restore normal urinary output and prevent further complications.

B. MRI is not an immediate priority when the client is at risk for kidney damage due to urinary retention.

C. While IV fluids may be necessary, the first priority is relieving the obstruction causing urinary retention.

D. Drawing blood is important for assessing the client's condition but is not as urgent as managing urinary retention.

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Correct Answer is A

Explanation

A. Tight shoes may indicate fluid retention in the lower extremities, which is a common symptom of right-sided heart failure. This condition leads to the backup of blood into the systemic circulation, causing peripheral edema.

B. Sleeping with two pillows may indicate left-sided heart failure, as the client may be experiencing orthopnea (difficulty breathing when lying flat).

C. Shortness of breath is more commonly associated with left-sided heart failure.

D. Waking up coughing every night is also a sign of left-sided heart failure, where pulmonary congestion leads to nocturnal coughing.

A. "I need to inform my allergist that I cannot take my normal antihistamine." B. "There should be no problem with drinking wine with dinner each night." C. "My routine of drinking a quart (liter) of water first thing in the morning needs to change." D. "I am so glad that I weaned myself off of coffee about a year ago."

Correct Answer is B

Explanation

A. Certain antihistamines can worsen urinary retention in BPH, so informing the allergist is a good practice.

B. Alcohol, including wine, can worsen the symptoms of BPH by increasing urinary retention and bladder discomfort. The client needs further teaching regarding the effects of alcohol on BPH symptoms.

C. It is advisable to avoid large volumes of fluids in the morning, as this can exacerbate BPH symptoms.

D. Caffeine can irritate the bladder and worsen BPH symptoms, so weaning off coffee is a helpful measure.

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A client who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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