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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Place the drainage bag above the level of the client's abdomen: This would impede drainage by gravity. The drainage bag should be below abdominal level to promote outflow.

B. Warm the dialysate solution prior to instillation: Warming the solution enhances diffusion, promotes comfort, and prevents abdominal cramping. Use a warming pad, not a microwave.

C. Monitor vital signs every 2 hours during the procedure: While vital signs are monitored, more frequent monitoring is often required during the initial phase or if the patient is unstable.

D. Maintain the client in a left lateral position during dialysis: The semi-Fowler’s position is preferred to facilitate flow and lung expansion, not lateral positioning.

A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds B. Client with facial burns and expectorating sooty secretions in no distress C. Client with dry, black skin on both hands and a history of diabetes mellitus D. Client with moist blisters over the back and who reports pain as 10

Correct Answer is A

Explanation

A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds: High-pitched respiratory sounds (stridor) suggest impending airway obstruction, which is life-threatening and requires immediate intervention.

B. Client with facial burns and expectorating sooty secretions in no distress: At risk for inhalation injury but not in immediate respiratory distress.

C. Client with dry, black skin on both hands and a history of diabetes mellitus: Eschar and possible full-thickness burns are serious but not immediately life-threatening compared to airway compromise.

D. Client with moist blisters over the back and who reports pain as 10: Pain is expected and manageable; airway takes priority.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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