The client is a 49-year-old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the emergency department (ED last night when he was having more difficulty breathing. He has a history of one-half pack a day cigarette smoking for 20 years. He has no significant medical or surgical history

The client has an oxygen saturation of 96% on 8 L simple face mask. The nurse assesses the client, and he is feeling less restless and anxious. His heart rate is now 79 bpm, blood pressure 119/73 mmHg, and respiratory rate 24.

What are the 3 most important goals that would help the nurse evaluate the treatment of this client at discharge?

The client will report pain less than 3/10

The client will have quit smoking

The client will remain free of skin breakdown

The client will maintain oxygen saturation of 96% without supplemental oxygen

The client will be afebrile for 24 hours

Answer and Explanation

Correct Answer : B,D,E

A. While managing pain is important, the client did not report significant pain, making it a lower priority in this scenario.
B. Quitting smoking is crucial for the client's respiratory health, especially given the history of smoking and current respiratory symptoms.
C. There is no indication that the client is at risk of skin breakdown; thus, it is not a priority in the immediate discharge plan.
D. Maintaining an oxygen saturation of 96% without supplemental oxygen is a direct indicator of improved respiratory function and a key goal for discharge.
E. Being afebrile for 24 hours would indicate that the infection is under control, which is a primary concern for discharge after presenting with flu-like symptoms.

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Correct Answer is D

Explanation

A. Client's healthcare power of attorney - This is important legal information but not the most immediate concern for the healthcare provider.

B. Currently prescribed medications - While important, this information does not represent an immediate change in the client's condition.

C. Fall at home as reason for admission - This is background information and, although important, is not the most pressing issue if the client's condition is worsening.

D. Increasing confusion of the client - The increasing confusion could indicate a change in the client's baseline mental status, which could be a sign of a serious condition such as a subdural hematoma or infection and should be communicated immediately.

A. Remove the catheter and palpate the client's bladder for residual distention. B. Allow the bladder to empty completely or up to 1,000 mL of urine. C. Clamp the catheter for thirty minutes and then resume draining. D. Remove the catheter and replace with an indwelling catheter.

Correct Answer is B

Explanation

A. Remove the catheter and palpate the client's bladder for residual distention:
This is not the next appropriate action. Palpating the bladder does not address the immediate need to relieve the remaining urine or monitor for signs of overdistension.

B. Allow the bladder to empty completely or up to 1,000 mL of urine:
Gradual emptying is recommended to prevent bladder spasms and circulatory compromise due to rapid decompression of a distended bladder. It is safe to continue draining the urine up to 1,000 mL in a controlled manner before considering clamping the catheter temporarily if needed.

C. Clamp the catheter for thirty minutes and then resume draining:
Clamping after draining only 500 mL is unnecessary. The bladder should be allowed to empty up to 1,000 mL first, as gradual decompression is generally safe and therapeutic. Clamping prematurely might cause unnecessary discomfort or delay effective bladder emptying.

D. Remove the catheter and replace with an indwelling catheter:
Replacing the catheter is not required unless there is a clinical indication, such as repeated urinary retention or prolonged voiding difficulties. A straight catheter is appropriate for one-time use unless otherwise specified.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

Correct Answer is B

Explanation

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