In assessing a client with an indwelling urinary catheter following the provision of care by an unlicensed assistive personnel (UAP), the practical nurse (PN) observes that the catheter drainage bag, which is half- full, is attached to the side rail and the tubing is looped on the bed.

Which action should the PN implement?

Apply gloves and empty the drainage bag

Remove the looped tubing from the bed

Measure the urinary output in the bag

Attach the drainage bag to the bed frame

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Attach the drainage bag to the bed frame.

Choice A rationale:

Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full.

Choice B rationale:

Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag.

Choice C rationale:

Measuring the urinary output in the bag is a routine task but does not correct the improper placement of the drainage bag.

Choice D rationale:

Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.

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Correct Answer is C

Explanation

Choice A rationale:

“Reflection is thinking about what I did and how I can improve.” Rationale: Reflection involves self-assessment and critical thinking about past actions to identify areas for improvement. This statement correctly defines reflection and does not indicate a need for further teaching.

Choice B rationale:

“Analysis is breaking down a complex situation into smaller parts.” Rationale: Analysis is the process of examining complex situations by breaking them down into smaller, manageable components for a more in-depth understanding. This statement accurately describes analysis and does not indicate a need for further teaching.

Choice C rationale:

“Inference is making assumptions based on my experience.” Rationale: Inference involves drawing conclusions or making predictions based on available evidence rather than personal experience. This statement incorrectly defines inference, indicating a need for further teaching.

Choice D rationale:

“Evaluation is checking the reliability and validity of information.” Rationale: Evaluation refers to the process of assessing the credibility, accuracy, and relevance of information or data. This statement accurately defines evaluation and does not indicate a need for further teaching.

A. Impaired physical mobility relative to muscle rigidity. B. Risk for aspiration relative to muscle weakness. C. Risk for constipation relative to immobility. D. Self-care deficit relative to motor disturbance.

Correct Answer is B

Explanation

Choice A rationale: Impaired physical mobility is a significant concern in Parkinson's disease due to bradykinesia and tremors. However, it does not pose an immediate threat to life when compared to potential airway and respiratory complications.

Choice B rationale: Aspiration is the highest priority according to the ABC (Airway, Breathing, Circulation) framework. Parkinson's causes dysphagia and impaired laryngeal reflexes, making silent aspiration and subsequent pneumonia a life-threatening risk for the client.

Choice C rationale: Constipation is common due to decreased GI motility and side effects of dopaminergic medications. While it causes discomfort and potential impaction, it is a physiological need that ranks lower than respiratory safety.

Choice D rationale: Self-care deficits in hygiene and dressing affect the client's quality of life and independence. In the hierarchy of care, these functional limitations are addressed only after the client's physical safety and airway are secured.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of nursing students about the components of critical thinking. Which of the following statements by a student indicates a need for further teaching?

Correct Answer is C

Explanation

In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

Correct Answer is B

Explanation

The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?

A client with bleeding esophageal varices receives vasopressin intravenously (IV). Which adverse effect should the nurse monitor for during the IV infusion of this medication?

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

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A nurse is teaching a client who has a fungal infection about fluconazole. Which of the following statements by the client indicates an understanding of the teaching?

When caring for an older male client with urinary frequency, which measure is most important for the nurse to implement to help the client prepare to go to bed for the night?