Patient Data

Exhibits

Review H and P and nurse's notes.

Identify 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 Conditions

Overflow urinary incontinence

This is the correct choice because overflow urinary incontinence is the involuntary loss of urine due to a distended bladder that cannot empty completely. The client has cerebral palsy, which can affect the bladder muscles and nerves, causing them to lose coordination and contractility. The client is also non-verbal and has severe intellectual disability, which can impair his ability to sense or communicate the need to void. The client's clothes and sheets are wet, indicating that he has leaked urine. The client voided approximately 75 mL of urine, which is a small amount for an adult male. These signs suggest that the client has overflow urinary incontinence.

Actions to Take

Provide skin care

This is a correct choice because the nurse should provide skin care to the client who has overflow urinary incontinence. The nurse should cleanse the perineal area with mild soap and water, pat dry, and apply a barrier cream or ointment to protect the skin from moisture and irritation. The nurse should also change the client's clothes and sheets as needed to keep him dry and comfortable.

Place an incontinence containment product under the client

This is a correct choice because the nurse should place an incontinence containment product under the client who has overflow urinary incontinence. An incontinence containment product is a device or material that absorbs or collects urine, such as a diaper, pad, or catheter. The nurse should choose an appropriate product based on the client's preferences, needs, and abilities. The nurse should also monitor the product for leakage, odor, or infection, and change it regularly.

Parameters to Monitor

Intake and output

This is a correct choice because the nurse should monitor the intake and output of the client who has overflow urinary incontinence. The nurse should measure and record the amount and type of fluids that the client consumes and excretes. The nurse should also note the color, clarity, odor, and specific gravity of the urine. The nurse should compare the intake and output with the normal ranges for the client's age, weight, and condition. The nurse should report any abnormal findings or changes to the health care provider.

Post-void residual

This is a correct choice because the nurse should monitor the post-void residual of the client who has overflow urinary incontinence. Post-void residual is the amount of urine left in the bladder after voiding. The nurse can measure it by using a bladder scanner or inserting a catheter after the client voids. A normal post-void residual is less than 50 mL for an adult male. A high post-void residual indicates that the bladder is not emptying completely, which can lead to overflow urinary incontinence. The nurse should report any high post-void residual to the health care provider.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A: Notify the healthcare provider is the correct action because it is the nurse's responsibility to report any medication errors or adverse reactions to the prescriber as soon as possible.

Choice B: Document the event on the chart is not the next action because it should be done after notifying the healthcare provider and completing an incident report.

Choice C: Complete an incident report is not the next action because it should be done after notifying the healthcare provider and before documenting the event on the chart.

Choice D: Inform the nurse on the next shift is not the next action because it should be done after documenting the event on the chart and during handoff.

A. Lead the client in guided imagery B. Give a dose of 2.5 mg of Morphine C. Assist the client to walk around the room D. Assess for sources of pain other than the surgical site E. Consult with the surgeon about the pain level

Correct Answer is ["A","D","E"]

Explanation

Choice A: Lead the client in guided imagery

This is a correct choice because guided imagery is a non-pharmacological intervention that can help reduce pain and anxiety by creating a relaxing mental image for the client. Guided imagery can also lower the heart rate and blood pressure by activating the parasympathetic nervous system.

Choice B: Give a dose of 2.5 mg of Morphine

This is an incorrect choice because morphine is an opioid analgesic that can cause respiratory depression, hypotension, and bradycardia. The client's heart rate is already elevated, which could indicate inadequate pain relief or anxiety. Giving more morphine could worsen the client's condition and mask the underlying cause of the pain.

Choice C: Assist the client to walk around the room

This is an incorrect choice because walking around the room could increase the client's pain and heart rate by stimulating the sympathetic nervous system. The client has already done ambulation exercises with physical therapy at 1200, so there is no need to repeat them at 1400. The client should be allowed to rest in bed and conserve energy.

Choice D: Assess for sources of pain other than the surgical site

This is a correct choice because the nurse should always assess the client holistically and rule out any other potential causes of pain, such as infection, inflammation, or ischemia. The nurse should also check the surgical site for any signs of bleeding, hematoma, or infection. The nurse should use a comprehensive pain assessment tool that includes the location, intensity, quality, duration, frequency, and aggravating and relieving factors of the pain.

Choice E: Consult with the surgeon about the pain level

This is a correct choice because the nurse should collaborate with the surgeon and other members of the health care team to provide optimal pain management for the client. The nurse should report the client's pain score, vital signs, medication administration, and response to interventions. The surgeon may order additional tests or medications to address the cause of the pain and improve the client's comfort.

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Patient Data Exhibits Review H and P and nurse's notes. Identify 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After an intravenous antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Correct Answer is A

Explanation

Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

The nurse is teaching a client about use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

A client with a prescription for morphine sulfate 0.2 mg intravenously every 4 hours as needed for pain reports that pain is a 10 out of 10 on the numeric pain scale one hour after receiving the last administration. Which intervention should the nurse implement?

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

A client's wife has just learned that her husband is terminally ill. She is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Patient Data

Exhibits

Review H and P and nurse's notes.

Identify 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.