At the end of a 12-hour shift, the practical nurse (PN) observes the urine in a client's drainage bag as seen in the picture. Which action should the PN take next?
Obtain a fingerstick capillary glucose level.
Note the most recent white blood cell count.
Offer to administer a prescribed PRN analgesic.
Determine if the client's bladder feels distended.
The Correct Answer is B
A. Obtain a fingerstick capillary glucose level: Glucose testing is not related to the color of the urine in the image, which appears cloudy and dark—signs suggestive of infection, not hyperglycemia.
B. Note the most recent white blood cell count: Cloudy urine, as shown in the picture, indicates a possible urinary tract infection (UTI). Reviewing the WBC count helps the nurse determine whether there is systemic infection or inflammation.
C. Offer to administer a prescribed PRN analgesic: Pain management is not the priority when the primary concern is infection; further assessment is required first.
D. Determine if the client's bladder feels distended: Bladder distention would cause low urine output, not discolored or cloudy urine, so palpation is not the next appropriate step
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Removes any air bubbles in syringe to ensure correct dosage: Expelling air bubbles before injection is proper technique, as it ensures that the full insulin dose is administered accurately. This step helps prevent underdosing and promotes consistent blood glucose control.
B. Injects into the same site selected for the previous dose: Repeatedly using the same injection site can lead to lipohypertrophy, thickened, fatty areas under the skin that interfere with insulin absorption. Clients should rotate injection sites within the same anatomical area to maintain consistent absorption and prevent tissue damage.
C. Uses a circular action when applying an alcohol pad to the site: Cleaning the site with a circular motion from the center outward is the correct technique to reduce surface bacteria. Allowing the area to dry before injection further minimizes discomfort and risk of infection.
D. Injects air into the insulin vial to displace the dose: Injecting air equal to the amount of insulin to be withdrawn prevents a vacuum from forming in the vial. This technique facilitates easier and more accurate withdrawal of the medication.
Correct Answer is ["600"]
Explanation
Convert all fluid intake from ounces (oz) to milliliters (mL) using the standard conversion factor of 1 oz = 30 mL.
0800: 4 oz apple juice × 30 mL/oz = 120 mL
1200: 8 oz milk × 30 mL/oz = 240 mL
1200: 4 oz broth × 30 mL/oz = 120 mL
1500: 4 oz tea × 30 mL/oz = 120 mL
Sum all the converted volumes to get the total intake in mL.
Total Intake (mL) = 120 mL (juice) + 240 mL (milk) + 120 mL (broth) + 120 mL (tea)
= 600 mL.
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