A nurse is assisting with the care of a client in a medical-surgical unit.

Vital Signs

05:00

Temperature 36.6 C (97.9 F)

Heart rate 100/min

Respiratory rate 22/min

Blood pressure 160/98 mm Hg

Oxygen saturation 96% on oxygen 2 L/min via nasal cannula

14:00

Temperature 36.8 C (98.3 F)

Heart rate 90/min

Respiratory rate 18/min

Blood pressure 138/88 mm Hg

Oxygen saturation 97% on oxygen 2 L/min via nasal cannula

Which of the following actions should the nurse take to decrease the risks for a urinary tract infection for this client? Select all that apply.

Encourage the client to drink 3,000 mL of ﬂuid daily.

Change the indwelling urinary catheter tubing every 3 days.

Place the drainage bag on the bed when transporting the client.

Empty the drainage bag when it is half-full.

Review the need for the indwelling urinary catheter daily.

Use soap and water to provide perineal care.

Answer and Explanation

Correct Answer : A,D,E,F

To decrease the risks for a urinary tract infection for this client, the nurse should take several actions. The nurse should encourage the client to drink 3,000 mL of ﬂuid daily to help ﬂush bacteria out of the urinary tract¹. The nurse should also empty the drainage bag when it is half-full to prevent bacterial growth¹.

Additionally, the nurse should review the need for the indwelling urinary catheter daily and use soap and water to provide perineal care¹.

Nursing Test Bank

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Correct Answer is B

Explanation

The guideline of being able to fit one finger between the mattress and the side of the crib ensures that there is a safe space to prevent entrapment and suffocation risks.

Placing a newborn on a pillow for sleep is unsafe. Infants should be placed on their backs to sleep on a firm, flat surface without pillows, blankets, or soft bedding. This reduces the risk of suffocation or sudden infant death syndrome (SIDS).

Attaching a pacifier to the newborn's clothing with a string is hazardous. Strings and cords pose a strangulation risk. Pacifiers should be used according to safe guidelines, but they should not be attached to the baby's clothing with any type of string or cord.

Placing a newborn's crib near a heat vent can result in overheating, which is a safety concern. It is important to keep the baby's sleep environment at a comfortable temperature without direct exposure to heat sources or drafts

A. "I can prevent nausea if I take the medication on an empty stomach." B. "I will report black stools to my doctor." C. "I will mix the medication with a full glass of water." D. "I can prevent constipation if I drink more milk while taking this medication."

Correct Answer is C

Explanation

a.Ferrous sulfateworks best when you take it on an empty stomach. However, taking ferrous sulfate on an empty stomach can actually increase the risk of gastrointestinal side effects, such as nausea. It is often recommended to take it with food to reduce nausea, even though absorption is best on an empty stomach. Thus, this statement does not indicate proper understanding.

b.Black stools are a common side effect of taking iron supplements and are usually not a cause for concern unless they are tarry or associated with other symptoms, which could indicate gastrointestinal bleeding. Reporting black stools to the doctor is typically not necessary unless the stool is tarry and has other concerning symptoms like abdominal pain or bleeding. This statement reflects a misunderstanding of common side effects.

c.Mixing ferrous sulfate elixir with a full glass of water is advisable because it helps dilute the medication, making it easier to swallow and reducing the risk of gastrointestinal irritation. This practice also ensures that the medication is taken completely. This statement indicates a correct understanding of how to take the medication properly.

d.While staying hydrated can help manage constipation, milk is not recommended with iron supplements because calcium in milk can interfere with the absorption of iron. Instead, increasing water intake, eating a high-fiber diet, and considering other dietary measures would be better advice for preventing constipation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a parent of a newborn about home safety precautions. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

A nurse in a provider's office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching?

The nurse is identifying tertiary prevention strategies to implement for this client. Exhibits Select the three actions the nurse should take.

A nurse is caring for a client who has anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective?

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement first?

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching?