The nurse is caring for a client who has a continuous bladder irrigation (CBI) infusing. At the end of the shift, the nurse calculates the urine output. The client received a total of 2700 mL of the irrigation and emptied a total of 3375 ml from the urine catheter. What should the nurse record as the client's true urine output?

-625 mL

+675 mL

+375 mL

-300 mL

Answer and Explanation

The Correct Answer is B

A. A negative output would imply that the client has produced less urine than the irrigation received, which is not the case here.
B.   The true urine output is 675 mL, calculated by subtracting the irrigation amount from the total urine collected.
C.   The calculation does not support this value, as it does not accurately reflect the total urine output after accounting for the irrigation.
D.   Similar to option A, a negative value does not apply here since the urine output exceeds the irrigation amount.

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Correct Answer is A

Explanation

A. This is a significant finding that warrants immediate notification. Changes in mental status in elderly patients can indicate a variety of issues, including infection (such as a urinary tract infection), dehydration, or other acute illnesses. Given that elderly patients are at higher risk for delirium and other cognitive changes, this finding should be taken seriously.
B. These vital signs are largely within normal limits for an elderly patient. While the blood pressure is on the higher side, the heart rate and respiratory rate are within acceptable ranges. Therefore, this does not warrant immediate notification unless other symptoms are present.
C. This statement is reassuring and suggests that the client is not experiencing complications related to the indwelling catheter, such as infection or obstruction. It does not indicate any need for immediate notification of the provider.
D. Cloudy urine with sediment can be indicative of a urinary tract infection (UTI) or other complications related to the indwelling catheter. While this finding is concerning and may require further evaluation, it is not as urgent as a change in mental status. It should still be reported to the healthcare provider but may not necessitate immediate action.

A. reduce the risk of blood vessel spasm. B. prevent platelet aggregation. C. dissolve the blood clot. D. prevent infection in the brain.

Correct Answer is C

Explanation

A. While blood vessel spasms can occur after a stroke, t-PA does not directly affect them.
B. Platelet aggregation is the process by which platelets stick together to form a clot. t-PA dissolves clots, but it does not prevent their formation.
C. Tissue plasminogen activator (t-PA) is a medication that can dissolve blood clots. In the case of a thrombotic stroke, a blood clot has blocked blood flow to the brain. By dissolving the clot, t-PA can restore blood flow and limit brain damage.
D. t-PA does not have any direct effect on the risk of infection in the brain.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for an elderly female client who has an indwelling catheter. Which data in the assessment warrants notification of the health care provider?

Correct Answer is A

Explanation

The nurse is caring for a client who had a thrombotic stroke in the Emergency Department. It has been less than 3 hours since the onset of symptoms. The rationale for using tissue plasminogen activator (t-PA) for this client is to:

Correct Answer is C

Explanation

The nurse caring for a 27-year-old female client diagnosed with acute lymphoblastic leukemia (ALL). She and her husband are concerned about the ability to eventually have children. What should the nurse include in the discussion with this client and her husband?

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

Which of the following statements should the nurse include in the postoperative teaching for a patient diagnosed with thyroid cancer who had a thyroidectomy and is receiving levothyroxine?

The nurse is caring for a client with peripheral arterial disease. Which statement, by the client, indicates that they need additional teaching?

The nurse is performing a health screening of a 37-year-old female client. Which factor(s) would alert the nurse that this client is at greatest risk for developing a stroke?

The nurse is caring for a male patient who complains about a small "lump" that he discovered in his right testicle. What would be the best response by the nurse?

The nurse receives report at 0700 on a client who has 500 mL of IV fluid left in the bag. The IV is running at 125 mL per hour. At what time should the nurse expect to change the bag (military time)?

A client, who has undergone a transurethral resection of the bladder tumor (TURBT), complains of bladder spasms and has continuous bladder irrigation running. Which nursing action is most appropriate for this problem?