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 D

Explanation

A. A blood pressure of 90/50 mm Hg is concerning, but it is less urgent than severe respiratory depression. The nurse should still assess this client promptly.

B. A temperature of 96° F (35.6° C) is mildly low and should be addressed, but it is not as critical as a severely low respiratory rate.

C. A pulse of 118 beats/min is elevated and may require monitoring, but it does not pose as immediate a threat as respiratory depression.

D. A respiratory rate of 6 breaths/min is critically low, which may indicate respiratory depression, particularly after anesthesia. Immediate assessment and intervention are needed to ensure adequate oxygenation and ventilation.

A. A breast lump that is small, mobile and rubbery in consistency. B. A breast nodule that is 1 cm in size, nontender, and fixed. C. Bilateral breast nodules that are tender with palpation. D. A breast lump that increases in size before the menstrual period.

Correct Answer is B

Explanation

A. A small, mobile, rubbery lump is often benign, such as a fibroadenoma.

B. A nontender, fixed breast nodule is concerning for malignancy, and further evaluation is necessary, such as imaging or biopsy.

C. Tender, bilateral nodules are commonly seen in benign conditions like fibrocystic breast changes, especially related to the menstrual cycle.

D. A lump that changes in size before menstruation is also typical of benign conditions like fibrocystic changes.

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Test Name	Results	Reference Range
WBC	12, 000	4, 000- 11, 000
Na+	149 mEq/L	135-145 mEq/L
K+	5.0 mEq/L	3.5- 5.0 mEq/L
Cl-	110 mEq/L	96-106 mEq/L
pH	7.34	7.35-7.45
PaCO2	34 mmHg	35- 45 mmHg
PaO2	78 mm Hg	80-100 mmHg
HCO3	21 mEq/L	22- 26 mEq/L

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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Explanation

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Correct Answer is B

Explanation

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