A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

Obtain a prescription for an indwelling urinary catheter.

Offer the client the bedpan every 2 hr.

Cleanse the perineum from back to front.

Encourage fluid intake at and between meals.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Indwelling urinary catheters can actually increase the risk of UTIs.
Choice B rationale:
Offering the bedpan every 2 hours may not be necessary or practical for all patients.
Choice C rationale:
Cleaning the perineum from back to front can introduce bacteria to the urinary tract, increasing UTI risk.
Choice D rationale:
Adequate hydration can help flush bacteria out of the urinary tract, reducing UTI risk.

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Correct Answer is A

Explanation

Choice A rationale:
Output of burgundy colored urine can indicate bleeding, which is a complication after TURP.
Choice B rationale:
A slight fever might be normal postoperatively. However, a high fever could indicate an infection.
Choice C rationale:
An urge to void despite having an indwelling urinary catheter can be a normal sensation following surgery.
Choice D rationale:
A pulse rate of 88/min is within the normal range (60-100/min).

A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.”. B. "Large incisions will be made in the eschar to improve circulation.”. C. "Dead tissue will be non-surgically removed.”. D. "This procedure involves placing the client into a shower and removing the dead tissue.”.

Correct Answer is B

Explanation

Choice A rationale:
This statement describes a skin graft, not an escharotomy.
Choice B rationale:
An escharotomy involves making large incisions in the eschar (burned tissue) to relieve pressure and improve circulation to the area.
Choice C rationale:
This statement describes debridement, which is the removal of dead tissue, but it is not specific to an escharotomy.
Choice D rationale:
This statement describes a method of debridement, not an escharotomy.

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A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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