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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Correct Answer is A

Explanation

Choice A Reason: This is correct because it reflects a measurable and realistic goal that addresses the client's problem of activity intolerance related to pain. Ambulation promotes circulation, prevents complications, and enhances recovery.

Choice B Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Avoiding pain-causing activity may lead to immobility and further complications.

Choice C Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Incision healing is an expected outcome of wound care, not activity.

Choice D Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Taking analgesics as prescribed may help relieve pain, but it does not promote activity.

A. Notify the healthcare provider. B. Document the event on the chart. C. Complete an incident report. D. Inform the nurse on the next shift.

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.

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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

Correct Answer is A

Explanation

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

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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.