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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Free Nursing Study Resources

Correct Answer is C

Explanation

c. New onset of hearing loss.

When collecting data from a client who is receiving gentamicin via IV infusion, the nurse should identify new onset of hearing loss as an adverse eﬀect of the treatment¹. Gentamicin can cause vestibulocochlear nerve damage, which can aﬀect hearing and balance¹.

A. Insist that the client explain the reason for their bruises. B. Inform the client that their child is being abusive toward them. C. Report suspected maltreatment to the appropriate agency. D. Confront the client's child about the client's injuries. E. Ask the client how the fracture occurred. F. Conduct the interview with the client privately.

Correct Answer is ["C","E","F"]

Explanation

c. Report suspected maltreatment to the appropriate agency.

e. Ask the client how the fracture occurred.

f. Conduct the interview with the client privately.

In a situation where maltreatment is suspected, it is important for the nurse to report their concerns to the appropriate agency. The nurse should also ask the client how the fracture occurred and conduct the interview with the client privately, without the presence of their child, to gather more information and assess the situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse eﬀect of the treatment?

Correct Answer is C

Explanation

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

Correct Answer is ["C","E","F"]

Explanation

A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan?

A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation procedures when caring for this client?

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A nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Besides obtaining an x-ray, which of the following methods should the nurse use to verify the placement?

A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?

A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take?