An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Give the client 8 ounces (236.5 mL) of water to drink.

Evaluate the client for bladder distention.

Instruct the client to attempt to urinate again.

Send the sample for laboratory evaluation.

Answer and Explanation

The Correct Answer is B

A. Giving the client water to drink might help produce more urine, but it does not address the immediate issue of potential bladder distention, which can cause discomfort and urinary retention.
B. Evaluating the client for bladder distention is the priority action. The symptoms of lower abdominal discomfort and difficulty urinating suggest possible urinary retention, which could be due to an enlarged prostate or other obstructive issues. Assessing for bladder distention will help determine if the bladder is full and if further interventions, such as catheterization, are needed.
C. Instructing the client to try urinating again may not be effective if the client is experiencing urinary retention, and it doesn't address the underlying issue.
D. Sending the few drops of urine for evaluation could provide some information but does not address the potential problem of bladder distention or retention.

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Correct Answer is C

Explanation

A. A thickened and bulging tympanic membrane typically indicates a middle ear infection, such as otitis media, not an external ear infection, and would not be expected in this case based on the symptoms described.
B. A retracted and non-mobile tympanic membrane suggests Eustachian tube dysfunction or fluid in the middle ear, which does not correlate with the external ear symptoms of itching, pain, and discharge after swimming.
C. A red, edematous ear canal with no visualization of the tympanic membrane is indicative of otitis externa, commonly known as "swimmer's ear." This condition is characterized by inflammation of the external auditory canal, often following water exposure, which matches the client’s symptoms and history.
D. A translucent, pearly gray and mobile tympanic membrane is the appearance of a normal tympanic membrane, which would not be expected in a client with the described symptoms of pain, itching, and discharge associated with otitis externa.

A. Report the client's abnormal lung sounds to the healthcare provider. B. Ask the client to cough and then auscultate at the site again. C. Measure the client's oxygen saturation with a pulse oximeter. D. Continue with the remainder of the client's physical assessment.

Correct Answer is D

Explanation

A. Vesicular breath sounds are normal lung sounds heard over most of the lung fields, including the bases. Therefore, they do not need to be reported as abnormal.
B. There is no indication that coughing is needed since the breath sounds are normal.
C. Measuring oxygen saturation is not necessary at this moment, as the vesicular sounds are a normal finding.
D. Vesicular sounds are expected, normal breath sounds in the lung bases. The nurse should continue with the remainder of the physical assessment.

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An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

Correct Answer is C

Explanation

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Correct Answer is D

Explanation

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