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.
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Related Questions
Correct Answer is A
Explanation
A. This statement indicates that the client may not fully understand the care required for the drainage tubes. Drainage tubes typically do not "fall out" on their own; they need to be removed by a healthcare provider. The client should be instructed to care for the tubes, monitor drainage, and report any concerns to their healthcare provider.
B. It is appropriate to measure the drainage each day and report it if it exceeds the expected amount. This helps ensure that the surgical site is healing properly.
C. The client should be cautious with the positioning of the drainage tubes to avoid kinking or pulling, which could interfere with drainage and cause complications.
D. A foul odor from the drainage could indicate an infection, so it is appropriate for the client to contact their primary healthcare provider if this occurs.
Correct Answer is A
Explanation
A. "I will make sure that my partner takes all the prescribed medication.": This is the correct answer. Expedited partner therapy involves treating the partner(s) without an initial clinical visit, so ensuring they take all prescribed medications is essential to prevent reinfection.
B. "I will have my partner take the antibiotics if any STI symptoms occur.": This is incorrect because the partner should take the antibiotics regardless of symptoms to effectively treat the infection.
C. "I will have my partner use a condom until I finish the antibiotics.": While condom use is important, it does not replace the need for the partner to receive treatment.
D. "I will tell my partner that it is important to be examined at the clinic.": Although important, expedited partner therapy aims to provide treatment without a clinic visit.
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