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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Laboratory specimen transport is a necessary task but does not involve immediate physiological stability or time-sensitive clinical intervention. Standard urine specimens should be delivered within one hour of collection to prevent bacterial overgrowth or chemical changes, but this does not supersede the urgent metabolic needs of a diabetic client awaiting medication. It remains a lower priority task compared to assessing blood glucose levels before scheduled insulin administration.

Choice B rationale

Feeding a client with upper extremity immobilization is an important task related to nutrition and comfort. However, this task does not carry the same immediate risk as potential hypoglycemia or hyperglycemia in a client requiring insulin. Nutritional assistance can be slightly delayed or scheduled around more critical diagnostic tasks. It follows the priority of physiological safety, where metabolic monitoring takes precedence over the physical assistance required for meal consumption.

Choice C rationale

Blood glucose monitoring is the highest priority because it directly impacts medication administration and safety. Short-acting insulin must be given based on current glucose levels to prevent adverse events. Normal fasting blood glucose ranges from 70 to 99 mg/dL. Performing this task first ensures the client receives their insulin and breakfast on time, preventing dangerous fluctuations in blood sugar that could lead to acute complications like diabetic ketoacidosis or hypoglycemia.

Choice D rationale

Condom catheter application is a routine skin integrity and hygiene task for managing urinary incontinence. While important for preventing skin breakdown and maintaining client dignity, it is not time-sensitive or life-threatening. This task can be safely deferred until after the AP has completed higher-priority clinical measurements like glucose checks. The nurse must delegate tasks based on the urgency of the client’s physiological needs and the potential for clinical instability.

Correct Answer is ["15"]

Explanation

63 Step 1 is 15 mg ÷ 5 mg × 5 mL.

Step 2 is 3 × 5 mL.

Step 3 is 15 mL. The nurse should administer 15 mL.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?

Correct Answer is C

Explanation

A nurse is preparing to administer metoclopramide 15 mg PO QID before meals and at bedtime for a client who has GERD. The amount available is metoclopramide 5 mg/5 mL. How many mL should the nurse administer?

Correct Answer is ["15"]

Explanation

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