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.

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Correct Answer is D

Explanation

A.Maintain low-level lights in common areas.Inadequate lighting can contribute to disorientation and falls. Well-lit areas with natural or soft lighting are preferable.

B.Give the client several meal options at lunchtime.Too many choices can be overwhelming and increase confusion. Instead, limiting choices (e.g., offering just two meal options) is a better approach.

C.Confront the client regarding inappropriate behavior.Confrontation can increase agitation and distress. Instead, redirection and gentle guidance are more effective strategies.

D. Use symbols in the communal room signage.Clients experiencing confusion and memory loss benefit from visual cues and simple, clear communication. Using symbols (such as pictures of a toilet for the restroom or a plate for the dining area) can help them navigate the environment more easily and reduce frustration.

A. A nurse discusses a client's postoperative complications during a shift report. B. A social worker reads a client's chart as a follow-up to a requested consultation. C. A facility risk manager includes information from a client's medical record in a written report. D. A nurse tells the chaplain that a client has a new diagnosis of cancer.

Correct Answer is D

Explanation

In this scenario, the nurse disclosed sensitive medical information about the client's diagnosis to someone who is not directly involved in the client's care or treatment. This disclosure violates the client's right to privacy and confidentiality.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss. Which of the following strategies should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is reviewing client confidentiality with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality?

Correct Answer is D

Explanation

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 collecting data from a client who received oxytocin 10 units IM 30 min ago for excessive vaginal bleeding. Which of the following findings should the nurse expect?

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a parent of a preschooler about immunizations. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hour creatinine clearance test. Which of the following statements should the nurse include in the teaching?

A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make?

A nurse is caring for a client who speaks a different language than the nurse. The client's partner tells the nurse that the client would like to go home against medical advice (AMA). Which of the following actions should the nurse take?