When entering a client's room, the nurse observes that the unlicensed assistive personnel (UAP) has lowered the head of the bed to change the linens for a client who is bedfast. Which observation requires the most immediate intervention by the nurse?
The urine meter attached to the urinary drainage bag is completely full.
A feeding is infusing at 40 mL/hour through an enteral feeding tube.
There is a large dependent loop in the client's urinary drainage tubing.
Purulent drainage is present around the insertion site of the feeding tube.
The Correct Answer is C
A. The urine meter attached to the urinary drainage bag is completely full. While this observation requires attention, it does not pose an immediate risk to the client's safety. The nurse should
empty the urine meter promptly to prevent overflow.
B. A feeding is infusing at 40 mL/hour through an enteral feeding tube. This rate of infusion is within the typical range for enteral feedings and does not indicate an immediate safety concern. However, the nurse should assess the client's tolerance to the feeding.
C. There is a large dependent loop in the client's urinary drainage tubing. A large dependent loop in the urinary drainage tubing can lead to urinary stasis and increase the risk of urinary tract
infections or catheter-associated complications. It requires immediate intervention to prevent complications.
D. Purulent drainage is present around the insertion site of the feeding tube. While purulent drainage indicates a potential infection at the insertion site, it may not require immediate
intervention unless the client exhibits signs of systemic infection such as fever or increased white blood cell count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["532"]
Explanation
1 ounce (oz) is approximately equal to 29.5735 milliliters (mL).
Given that the client consumed:
- 4 ounces of protein shake
- 1 cup (which is typically 8 fluid ounces) of black coffee
- 6 ounces of apple juice
Calculation
- Protein shake: 4 ounces 29.5735 mL/ounce = 118.294 mL
- Black coffee: 8 ounces 29.5735 mL/ounce = 236.588 mL
- Apple juice: 6 ounces 29.5735 mL/ounce = 177.441 mL
Summing up the intake:
Total intake = Protein shake + Black coffee + Apple juice Total intake = 118.294 mL + 236.588 mL + 177.441 mL Total intake = 532.323 mL
Rounded off to the nearest whole number = 532mL
Correct Answer is C
Explanation
A. Bunions. While bunions can be uncomfortable and affect mobility, they are not directly related to nutritional status and may not require immediate nutritional assessment.
B. Sweaty palms. Sweaty palms can be a normal physiological response or related to factors such as anxiety or hyperhidrosis. It is not typically indicative of a nutritional issue.
C. Fatigue. Fatigue can be a symptom of various nutritional deficiencies or imbalances, including inadequate calorie intake, insufficient carbohydrate intake, or deficiencies in vitamins and
minerals such as iron or B vitamins. Further assessment is needed to determine the cause of the fatigue and whether it is related to the client's nutritional status.
D. Dry skin. Dry skin can also be a symptom of various issues, including dehydration, environmental factors, or skin conditions. While it can sometimes be associated with nutritional deficiencies, fatigue is a more concerning symptom in a professional dancer, as it can significantly affect performance and may indicate underlying nutritional issues.
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