Exhibits

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

Answer and Explanation

The Correct Answer is []

Potential Condition
Urinary Retention
The client's symptoms, including the urge to void, feeling "wet," and the bladder scan showing 600 mL of residual urine, suggest urinary retention. Urinary retention occurs when the bladder does not empty completely or at all, leading to a buildup of urine. This can happen postoperatively due to anesthesia effects, pain, or bladder dysfunction.
Actions to Take
• Request prescription for straight catheter

A straight catheter (intermittent catheterization) is used to drain the bladder and measure the amount of urine collected. It is often preferred over an indwelling catheter in cases of acute urinary retention where temporary relief and assessment of bladder function are needed.
•   Insert indwelling urinary catheter
An indwelling urinary catheter might be needed if urinary retention persists and is not relieved by other methods. It allows continuous drainage of urine and can be useful in managing acute or severe cases of urinary retention.
Parameters to Monitor
•   Amount of urine output
Monitoring urine output is crucial to evaluate how effectively the bladder is emptying after catheterization or other interventions. This helps in assessing whether the urinary retention is being resolved.
•   Residual urine
Checking residual urine with a bladder scanner can help determine how much urine remains in the bladder after voiding. Persistent high residual urine levels would indicate ongoing retention issues that need further intervention.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. While hypercalcemia associated with hyperparathyroidism can lead to neurological symptoms, seizures are not a typical presentation of kidney stones.
B. Sudden onset of severe flank pain in a client with hyperparathyroidism is highly suggestive of a kidney stone. Straining the urine to check for stones is a crucial nursing action.
C. Laxatives are not indicated for the management of kidney stones.
D. While hypercalcemia can lead to cardiac arrhythmias, this is not the immediate priority when the client is experiencing severe flank pain suggestive of kidney stones.

A. Fatigue related to disease exacerbation. B. Pain related to joint inflammation C. Impaired physical mobility related to joint pain. D. Self-care deficit related to disease progression.

Correct Answer is B

Explanation

A. This is a valid nursing problem and directly related to the client's condition. However, while fatigue is a significant concern, it is often a symptom of other underlying issues.

B. This is the highest priority nursing problem. Pain is a primary symptom of acute RA exacerbation and significantly impacts the client's quality of life, mobility, and overall well-being. Addressing pain is crucial for immediate comfort and to facilitate other interventions.
C. This is also a valid nursing problem, directly linked to the client's symptoms. However, it is a consequence of the pain, not the primary issue. Addressing the pain will improve mobility.
D. This is a potential long-term concern but not the highest priority at this acute stage. The client's immediate needs related to pain and mobility are more pressing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?

Correct Answer is B

Explanation

A client is admitted with heart failure (HF) and left ventricular hypertrophy. Which intervention is most likely to avert development of cardiomegaly and improve myocardial contractility?

The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "Imbalanced nutrition, less than body requirements." Which cause is most likely contributing to the problem?

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse? Reference Range: Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)] .

Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?