The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.
The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Keep the bed in the lowest position and initiate seizure and fall precautions.

Place an indwelling urinary catheter and measure strict intake and output.

Maintain elevated positioning of the dependent joints on affected side.

Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Answer and Explanation

The Correct Answer is D

Choice A reason: Keeping the bed in the lowest position and initiating seizure and fall precautions is not an immediate action for the nurse to take. Seizure and fall precautions are measures that prevent injury or harm to the client in case of a seizure or a fall. Seizure and fall precautions include lowering the bed, padding the side rails, removing any objects that may cause injury, and having suction and oxygen equipment ready. However, these precautions are not specific to the client's condition and do not address the underlying cause.

Choice B reason: Placing an indwelling urinary catheter and measuring strict intake and output is not an urgent action for the nurse to take. An indwelling urinary catheter is a tube that drains urine from the bladder into a collection bag. Measuring intake and output is a way of monitoring fluid balance and kidney function. However, these interventions are not essential for the client's condition and may increase the risk of infection or trauma.

Choice C reason: Maintaining elevated positioning of the dependent joints on affected side is not a relevant action for the nurse to take. Dependent joints are joints that are below the level of the heart, such as the ankles or wrists. Elevating dependent joints can help reduce swelling or pain by improving blood flow and drainage. However, this intervention is not related to the client's condition and does not improve neurological function.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A: Measuring urine output daily is not a specific statement for the nurse to include, as this is a general recommendation for all clients with urinary catheters and does not address the potential complications of a suprapubic catheter. This is a distractor choice.

Choice B: Observing urine color and clarity is not a relevant statement for the nurse to include, as this does not reflect the condition of the suprapubic catheter or its insertion site. This is another distractor choice.

Choice C: Inspecting genital area for signs of infection is an important statement for the nurse to include, as this can help detect and prevent urinary tract infection, peritonitis, or abscess formation, which are common risks associated with suprapubic catheters. Therefore, this is the correct choice.

Choice D: Palpating flank area for tenderness is not a necessary statement for the nurse to include, as this is not an accurate or reliable method to assess for kidney function or damage, which are unlikely to occur with a suprapubic catheter. This is another distractor choice.

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

Choice A: Remove the catheter and palpate the client’s bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.

Choice B: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.

Choice C: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.

Choice D: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is C

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

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

The nurse leading a cardiac team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse assign to the PN?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statementby the client indicates understanding?

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED. with full thickness burns on both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom.
The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?