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

A. Cool and clammy skin:
May indicate shock but is not specific to electrical burns.

B. Purulent drainage from the burn site:
Suggests infection, a later complication rather than immediate concern.

C. Muscle weakness:
Can occur but is less urgent than cardiac effects.

D. Irregular heart rhythm:
Electrical burns can cause internal cardiac damage and arrhythmias-potentially life-threatening.

A. Orange juice B. Bananas C. Grapefruit juice D. Smoked salmon

Correct Answer is C

Explanation

A. Orange juice: Does not affect cyclosporine metabolism.

B. Bananas: No known interaction with cyclosporine.

C. Grapefruit juice: Inhibits CYP3A4 enzyme in the liver, which increases cyclosporine levels, leading to toxicity.

D. Smoked salmon: May contain sodium but does not interact with cyclosporine metabolism.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has an electrical burn. Which of the following cues should the nurse recognize as indicating a potential complication of the burn injury?

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. The nurse recognizes that which pain management strategy should best meet this client's pain control needs?

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 65-year-old patient is admitted to the hospital with complaints of decreased urine output, fatigue, and swelling in the legs. Which of the following clinical cues is most indicative of acute kidney injury?

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?

A nurse is caring for a client experiencing fatigue secondary to anemia from chronic kidney disease (CKD). How should the nurse respond when the client asks about the cause of the anemia symptoms they are experiencing?

A nurse is conducting an assessment of a client with a severe circumferential burn injury to the forearm. Which of the following assessments should the nurse prioritize? (Select All that Apply.)

Patient presented for follow up of major burn injury. Exhibits A nurse is caring for a client recovering for 12 months from major burns that affected 60% total body surface area (TBSA). Which of the following complications should the nurse expect? (Select all that apply)