A nurse is delegating the collection of urinary output to an assistive personnel (AP). What should the nurse tell the AP to do while measuring the urine?

Tell the client to wash the urethra before voiding.

Wear gloves when handling a client's urine.

Use a clean measuring cup for each voiding

Compare the amount of output with intake

Answer and Explanation

The Correct Answer is B

a) Tell the client to wash the urethra before voiding: While it is important for patients to maintain hygiene, instructing them to wash the urethra is not a necessary step for APs collecting urine output. It is important for the AP to focus on measuring output.

b) Wear gloves when handling a client's urine: The AP should always wear gloves when handling bodily fluids, including urine, to prevent contamination and the spread of infection.

c) Use a clean measuring cup for each voiding: Using a clean measuring cup is important for accurate measurements, but the focus here should be on wearing gloves and correctly measuring the urine.

d) Compare the amount of output with intake: Comparing output with intake is the responsibility of the nurse, not the AP. The AP should focus on collecting and accurately measuring the urine output.

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Correct Answer is C

Explanation

a) Assess manifestations of malnutrition: While assessing for malnutrition is important, it is not a direct intervention to stimulate appetite.

b) Recommend dietary supplements: While dietary supplements can help improve nutritional intake, they are not an immediate intervention to stimulate appetite.

c) Encourage or provide oral care: Oral care, including brushing teeth and providing mouthwash, can help remove unpleasant tastes and promote a more comfortable eating experience, which may stimulate appetite.

d) Administer prescribed medications: While medications may be prescribed for appetite stimulation (e.g., megestrol), the nurse can implement independent interventions like oral care before resorting to pharmacological solutions.

A. Respiratory Decompression B. Respiratory Alkalosis C. Respiratory PH D. Respiratory Acidosis

Correct Answer is D

Explanation

a) Respiratory Decompression: "Respiratory Decompression" is not a term used in ABG interpretation.

b) Respiratory Alkalosis: Respiratory alkalosis is characterized by a pH greater than 7.45 and a PaCO2 less than 35 mm Hg. In this case, the pH is low (7.31), and the PaCO2 is elevated, which is not consistent with respiratory alkalosis.

c) Respiratory PH: "Respiratory PH" is not a proper ABG term.

d) Respiratory Acidosis: The pH is 7.31, which is acidotic (normal range is 7.35-7.45). The PaCO2 is 50 mm Hg (elevated), indicating that the cause of the acidosis is respiratory in nature, as the kidneys have not yet compensated with HCO3 (bicarbonate).

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A nurse is delegating the collection of urinary output to an assistive personnel (AP). What should the nurse tell the AP to do while measuring the urine?

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Naxlex Comprehensive Predictor Exams

What independent nursing intervention can be implemented to stimulate appetite?

Correct Answer is C

Explanation

Arterial blood gases (ABGs) have been drawn on the client. The nurse reviews the results. pH is 7.31 PaCO2 50 mm Hg (6.65 kPa) HCO3 26 mEq/L (26 mmol/L) How will the nurse interpret these ABG results.

Correct Answer is D

Explanation

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