A nurse is caring for a client in the medical-surgical unit.
Provider Prescriptions 0500:
Administer oxygen 2 L/min via nasal cannula Monitor intake and output. Fluid restriction of 1000 mL daily
1000:
Insert indwelling urinary catheter/ Vital Signs
0500:
Temperature 36.6° C (97.9° F) Heart rate 100/min Respiratory rate 22/min
BP 160/98 mm Hg
Pulse oximetry 96% on oxygen 2 L/min via nasal cannula 1400:
Temperature 36.8° C (98.2° F)
Heart rate 90/min Respiratory rate 18/min BP 138/88 mm Hg
Pulse oximetry 97% on oxygen 2 L/min via nasal cannula Laboratory Results
0600:
Calcium 9.3 mg/dL (9.0 to 10.5 mg/dL) Chloride 105 mEq/L (98 to 106 mEq/L)
Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Phosphate 4.1 mg/dL (3 to 4.5 mg/dL) Potassium
4.5 mEq/L (3.5 to 5.0 mEq/L) Sodium 149 mEq/L (136 to 145 mEq/L) Admission Assessment
0500:
Client admitted from emergency department with heart failure. Crackles auscultated bilaterally throughout lung fields. Lower extremities cool and dry with 1+ pedal pulses and 3+ pitting edema bilaterally.
Capillary refill 2 seconds.
Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client?
Select all that apply.
Use soap and water to provide perineal care.
Change the indwelling urinary catheter tubing every 3 days
Encourage the client to drink 3000 ml of fluid daily.
Review the need for the indwelling urinary catheter daily
Place the drainage beg on the bed when transporting the client
Correct Answer : A,D,E
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. The natural loss of deciduous (baby) teeth typically begins around 6 years of age, not at 2 years old.
B. Correct. Toddlers often have a nontender, protruding abdomen due to their underdeveloped abdominal muscles.
C. Incorrect. The fontanels (soft spots on the baby's head) should be closed by 18-24 months of age. Palpable fontanels at 2 years old could indicate abnormal cranial development.
D. Incorrect. It is not typical for a 2-year-old's head circumference to exceed their chest circumference. Head circumference is usually greater in infants but gradually becomes similar to chest circumference by 1-2 years of age.
Correct Answer is D
Explanation
Choice A rationale:
Oxytocin is not typically administered during a nonstress test. Oxytocin is a hormone that induces or augments labor contractions; it is not used in nonstress testing, which monitors fetal heart rate and movement. The administration of oxytocin during nonstress testing would not be appropriate or necessary.
Choice B rationale:
Fasting is not required for a nonstress test. Nonstress testing involves attaching electronic fetal monitors to the mother's abdomen to measure the baby's heart rate and movement. It does not require the patient to abstain from eating or drinking. Imposing unnecessary restrictions on the client's diet could cause discomfort and anxiety, which is not conducive to an accurate assessment.
Choice C rationale:
Nonstress testing is used to evaluate the baby's heart rate response to its own movements. It does not diagnose genetic problems. Genetic testing, such as amniocentesis or chorionic villus sampling, is a different type of test used to detect genetic abnormalities in the fetus. Therefore, this statement does not reflect an understanding of the purpose of nonstress testing.
Choice D rationale:
This is the correct answer. Nonstress testing involves monitoring the baby's heart rate and movement. During the test, the mother pushes a button when she feels the baby move. This allows the healthcare provider to correlate fetal movements with changes in the baby's heart rate. An understanding of this process indicates that the client comprehends the purpose and procedure of the nonstress test.
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