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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Digoxin is used to control the heart rate in atrial fibrillation but does not directly prevent the common complication of thromboembolism.
B. Warfarin is an anticoagulant used to prevent thromboembolic complications, such as stroke, which are common in atrial fibrillation due to the formation of clots in the atria.
C. Furosemide is a diuretic used to manage fluid retention, often in heart failure, but it does not prevent thromboembolism.
D. Lisinopril is an ACE inhibitor used to manage hypertension and heart failure, but it does not prevent thromboembolic complications.
Correct Answer is C
Explanation
A. Heparin is an anticoagulant and does not typically cause bronchospasm or wheezing.
B. Morphine can cause respiratory depression but not bronchospasm.
C. Propranolol, a non-selective beta-blocker, can cause bronchospasm, particularly in clients with asthma.
D. Nitroglycerin primarily causes vasodilation and does not typically lead to bronchospasm or wheezing.
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