A nurse is caring for a client on the medical-surgical unit.

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Urinary Tract Infection (UTI)
The client is reporting frequency, burning, and urgency, classic symptoms of a lower UTI (cystitis). The recent removal of the urinary catheter (which increases infection risk) further supports this.

Actions to take:

Check a urine culture and sensitivity: A urine culture will confirm the presence of infection and identify the specific organism, allowing for appropriate antibiotic selection.
Request a prescription for an antispasmodic agent: Bladder spasms can contribute to frequency and urgency, especially post-catheter removal. An antispasmodic (e.g., oxybutynin) may help relieve discomfort.

Parameters to monitor:

Temperature: Fever can indicate progression of the UTI to pyelonephritis or worsening infection. The current low-grade fever of 100.4°F may be an early sign.
Fluid intake: Adequate hydration helps flush bacteria from the urinary tract and is essential in promoting recovery from a UTI.

Incorrect diagnoses:

The post-void residual is only 22 mL, which rules out urinary retention. No evidence points to STIs like gonorrhea, nor to incontinence.

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Correct Answer is D

Explanation

Formula: 4 mL × Body weight (kg) × %TBSA

4 × 100 × 40 = 16,000 mL total in 24 hours

Half (8,000 mL) is given in the first 8 hours

Answer- 8000ml

A. Skin is red, blanches, and weeps B. Skin has a leathery and dry C. Skin is waxy in appearance D. Skin is intact, dry, and red in color

Correct Answer is A

Explanation

A. Skin is red, blanches, and weeps: This is consistent with deep partial-thickness burns. These burns damage deeper layers but still allow capillary refill and exudate.

B. Skin has a leathery and dry: This is characteristic of full-thickness (third-degree) burns.

C. Skin is waxy in appearance: A waxy appearance suggests full-thickness burns.

D. Skin is intact, dry, and red in color: This indicates superficial (first-degree) burns like sunburn.

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Naxlex Comprehensive Predictor Exams

A nurse is monitoring the fluid replacement of a client who has sustained burns over 40% total body surface area (TBSA). The client weight is 100kg According to the Parkland Formula, how much fluid will the client require in the first 8 hours?

Correct Answer is D

Explanation

A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?

Correct Answer is A

Explanation

A nurse is caring for a client receiving a hemodialysis treatment. Which of the following complications should the nurse recognize when the client becomes restless and reports nausea and headache?

A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?

A nurse has accepted care of a client with a major burn injury. The burns are 2nd and 3rd degree and estimated at 45% of total body surface area (TBSA). In addressing the pathophysiologic changes resulting from major burns the nurse is aware that the priority intervention for this client is?

A nurse is assessing a client who has sustained burns on the entire left arm and the anterior chest. Using the rule of nines, the nurse calculates what percentage of total body surface area is affected by the burns?

A nurse is preparing to care for a client after a full thickness chemical burn of the bilateral lower extremities. The nurse is aware that 3rd degree, full thickness burns affect which of the following? Select all that apply.

A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse Implement to ensure proper dialysate exchange?

A nurse is caring for a client who is prescribed cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can increase cyclosporine levels to a toxic level?

A nurse is reviewing the medication record for a client diagnosed with chronic kidney disease (CKD). Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity?