Exhibits

Review H and P and nurse's note.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the practical nurse (PN) should take to address that condition, and two parameters the PN should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Overflow urinary incontinence: Overflow incontinence occurs when the bladder becomes overly full and urine leaks out because it cannot empty properly. The client’s limited communication ability, along with wet clothes and sheets despite voiding only 75 mL of urine, suggests that the bladder is not emptying fully. This is consistent with overflow incontinence, which is often seen in individuals with neurological impairments like cerebral palsy, where bladder control is compromised.
Urge incontinence: Urge incontinence occurs when the client has a sudden, intense urge to void, followed by involuntary leakage before reaching the bathroom. The client’s symptoms, including wet clothing and a small volume of urine, do not suggest an overwhelming urge to urinate. Given the client’s cognitive and communicative impairments, urge incontinence is less likely than overflow incontinence, which fits better with the clinical presentation.
Reflex urinary incontinence: Reflex urinary incontinence occurs due to a loss of voluntary control over bladder function, often following a spinal injury. While the client has a neurological condition (cerebral palsy), there is no indication of spinal cord injury or other factors typically associated with reflex incontinence. The clinical signs and small urine voided suggest overflow incontinence, where the bladder fills beyond capacity, rather than reflex incontinence.
Teach the client to use mobility aids: Teaching mobility aids is not an appropriate intervention for overflow incontinence. Since the primary issue is the inability to empty the bladder fully, mobility aids won’t address the underlying problem. Overflow incontinence requires direct management of the bladder, such as catheterization or bladder training, rather than enhancing mobility.
Provide skin care: Skin care is critical in clients with incontinence, as wetness can lead to skin irritation and breakdown. Given that the client is in adult diapers and has urinary leakage, skin care must be prioritized. Proper hygiene, moisture management, and the use of skin barriers will help prevent skin damage and infections, which are common complications in clients with urinary incontinence.
Place an indwelling catheter: Since the client is unable to communicate the need to void and may not empty his bladder fully, placing an indwelling catheter is an appropriate intervention. It will help ensure proper drainage of urine and prevent complications related to overflow incontinence, such as bladder distention, infection, and skin breakdown.
Blood pressure: Blood pressure monitoring is not directly relevant to the management of overflow incontinence. While important for general health, blood pressure does not provide specific insight into bladder function or urinary incontinence. The focus should be on bladder management and preventing skin breakdown, not blood pressure in this case.
Post-void residual: Monitoring post-void residual (PVR) is crucial in assessing overflow incontinence. A high PVR indicates that the bladder is not emptying completely, which is characteristic of overflow incontinence. Measuring PVR can guide decisions about catheterization and help track the effectiveness of interventions aimed at improving bladder function.
Intake and output: Monitoring intake and output is useful in managing fluid balance but does not directly address overflow incontinence. While important for general health, it won’t provide the specific information needed to address bladder function and urinary leakage in the context of overflow incontinence.
Skin integrity: Skin integrity is a priority in clients with incontinence, as prolonged moisture exposure can lead to skin breakdown and infections. Given that the client is in adult diapers and has wet clothing, regular monitoring and care of the skin are essential to prevent complications like pressure ulcers and dermatitis associated with urinary leakage.

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Correct Answer is []

Explanation

Hyponatremia: The client's sodium level of 130 mEq/L is below the normal range (136–145 mEq/L), indicating hyponatremia. Symptoms like weakness, brain fog, and dehydration are typical signs. Immediate correction is necessary to prevent complications such as seizures or coma.
Metabolic Alkalosis: Metabolic alkalosis is unlikely here, as vomiting typically leads to a loss of acid, not an increase. The client's symptoms and lab results suggest hyponatremia rather than alkalosis, which doesn’t match the clinical presentation.
Hyperkalemia: The potassium level of 3.4 mEq/L is slightly below the normal range, not elevated. Hyperkalemia, which causes muscle weakness and arrhythmias, is not supported by the client's lab values, making it an unlikely diagnosis.
Hypovolemia: While the client may be experiencing hypovolemia due to fluid loss, the primary concern is hyponatremia. The signs of dehydration (poor skin turgor, dry mucous membranes) are secondary to the electrolyte imbalance, not the primary issue.
Infuse a bolus of IV fluids: Given the client’s dehydration and low sodium level, infusing a bolus of IV fluids, especially those containing sodium, is essential. This helps correct fluid loss and addresses the hyponatremia, improving hydration status and electrolyte balance.
Request prescription for antiemetic: Controlling the client’s vomiting with an antiemetic is necessary to prevent further fluid and electrolyte loss. This will allow for better fluid retention and reduce the risk of exacerbating hyponatremia and dehydration.
Monitor lab values every six hours: Regular lab tests every six hours allow for monitoring the client’s sodium and potassium levels, as well as assessing the effectiveness of the fluid resuscitation. This will ensure the condition is progressing and adjustments can be made if needed.
Neurological status: Hyponatremia can cause neurological symptoms, including confusion and lethargy. Monitoring the client’s neurological status is crucial to assess the severity of the condition and detect any worsening of symptoms that may indicate more severe imbalances.
Oral intake: Although oral intake is important, the client is likely unable to tolerate enough fluids due to vomiting. IV fluid administration is the immediate solution for rehydration, with oral intake becoming more relevant once vomiting is controlled.
Electrocardiogram: Monitoring the ECG is critical to detect arrhythmias, which can result from electrolyte imbalances like hyponatremia. Sodium and potassium disturbances can affect heart rhythms, so regular ECG monitoring helps identify any cardiac complications.
Oxygen saturation: While important, oxygen saturation is not the primary concern here. The immediate need is to correct fluid and electrolyte imbalances. Oxygen levels should still be monitored, but they are secondary to managing the hyponatremia and dehydration.

A. Limit ROM assessment to the lower extremities only. B. Defer ROM assessment because of the respiratory rate. C. Ask client to perform flexion and extension of arms 5 times. D. Observe the client performing lateral flexion of the waist.

Correct Answer is B

Explanation

A. Limit ROM assessment to the lower extremities only: Focusing only on the lower extremities does not fully address the concern. Any physical exertion could further strain the respiratory system when the client is already tachypneic and in distress.
B. Defer ROM assessment because of the respiratory rate: A respiratory rate of 30 breaths per minute indicates respiratory distress. Physical exertion, even mild, could worsen oxygenation issues. Protecting respiratory function is the priority, so the ROM assessment should be deferred until the client's condition stabilizes.
C. Ask client to perform flexion and extension of arms 5 times: Even minimal arm movements could increase oxygen demand and fatigue in a client already experiencing respiratory compromise, making this unsafe at the moment.
D. Observe the client performing lateral flexion of the waist: Lateral flexion involves significant muscular effort and could further tax respiratory function. It is not appropriate when the client is tachypneic and needs respiratory support.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

While performing a physical assessment on a client with chronic obstructive pulmonary disease (COPD), the practical nurse (PN) determines that the client's respiratory rate is 30 breaths/minute. When the PN begins to assess the client's range of motion (ROM), which is the best plan to implement?

Correct Answer is B

Explanation

During vital sign assessment of a client, the practical nurse (PN) counts the left radial pulse at 88 beats/minute, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 beats/minute with an oxygen saturation of 95%. Which of the following should the PN do first?

In providing daily catheter care for a client with a condom catheter, which action should the practical nurse (PN) include?

When initiating a 24 hour urine collection, which action should the practical nurse (PN) take?

After accepting employment in a state different from where a practical nurse (PN) is currently employed, it is most important for the PN to review which reference?

While applying sterile gloves (open method), which action should the practical nurse (PN) take to ensure that surgical asepsis is maintained?

The practical nurse (PN) has been regularly assigned the care of an older adult client who resides in a long term care facility. When the client is told that they have a terminal illness, which action is best for the PN to take?