An older adult woman has just been admitted to a long-term care center. The EMT discloses the client has not had urine output for the last 8 hours per the shift report provided to them. Which of the following should be the nurse's priority action?
Place an indwelling catheter.
Perform a bladder scan.
Ask the client to increase their fluid intake.
Perform intermittent catheterization.
The Correct Answer is B
Choice A rationale
Placing an indwelling catheter is an invasive procedure that carries a significant risk of urinary tract infection, especially in older adults. It should only be performed after less invasive diagnostic measures have confirmed the presence of retained urine and other interventions have failed. Jumping straight to catheterization violates the principle of using the least invasive intervention first and does not provide diagnostic information regarding why the output has ceased over the last eight hours.
Choice B rationale
Performing a bladder scan is the priority action because it is a non-invasive bedside diagnostic tool that immediately quantifies the volume of urine in the bladder. Normal post-void residual is typically less than 50 mL to 100 mL. This assessment helps the nurse differentiate between urinary retention, where the bladder is full but cannot empty, and decreased urine production, which might indicate dehydration or renal failure. Assessment must always precede intervention in the nursing process.
Choice C rationale
Asking the client to increase fluid intake is an intervention that should only be implemented once the cause of the low urine output is determined. If the client is suffering from urinary retention due to an obstruction, such as an enlarged prostate or a blockage, increasing fluids will exacerbate the bladder distension and increase discomfort or risk of bladder injury. The nurse must first use a bladder scan to determine if urine is actually present.
Choice D rationale
Intermittent catheterization is an intervention used to drain the bladder when a client cannot void spontaneously. While it has a lower risk of infection than an indwelling catheter, it is still an invasive procedure. The nurse should first perform a non-invasive bladder scan to confirm that the bladder contains enough urine to warrant catheterization. Without an initial assessment of bladder volume, this action is premature and could cause unnecessary discomfort or risk for the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Milk and other dairy products contain proteins such as orotic acid and casein that actually promote the excretion of uric acid via the kidneys. Regular consumption of low-fat dairy products is associated with a decreased risk of gout flares rather than acting as a trigger. Therefore, advising a client to consume milk can be beneficial for managing their condition because it lacks the purines found in many other protein sources.
Choice B rationale
Coffee consumption has been scientifically linked to lower levels of serum uric acid in many clinical studies. The mechanism is thought to involve the competitive inhibition of the enzyme xanthine oxidase by caffeine or other phenolic compounds, which reduces the production of uric acid. Moderate coffee intake is generally considered safe or even protective for individuals with gout, making it an unlikely trigger for an acute inflammatory attack or painful joint swelling.
Choice C rationale
Alcohol consumption, particularly beer and distilled spirits, significantly increases the production of uric acid and interferes with its excretion by the kidneys. High purine content in beer leads to hyperuricemia, while ethanol increases the metabolic breakdown of nucleotides. This dual effect results in the crystallization of monosodium urate in the joints, which triggers the intense inflammatory response, pain, and swelling characteristic of a gout flare-up. Alcohol should always be avoided.
Choice D rationale
Orange juice is high in naturally occurring fructose. Fructose metabolism in the liver leads to the rapid depletion of adenosine triphosphate, which results in the increased production of adenosine monophosphate and subsequently uric acid. While fructose is a known contributor to hyperuricemia, alcohol is a much more potent and clinically significant trigger for acute attacks in most gout patients. Orange juice is less likely to be the primary cause compared to ethanol.
Correct Answer is ["90"]
Explanation
Step 1 is 6 tablespoons × 15 mL ÷ 1 tablespoon.
Step 2 is 90 mL.
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