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 D
Explanation
A. Baked potato with low fat butter. While this is a low-fat option, it lacks a significant amount of protein, making it an inadequate substitute for a protein-rich meal like a hamburger.
B. One slice of cheese pizza. Cheese pizza still contains a considerable amount of saturated fat due to the cheese and possible meat toppings.
C. Salad greens with tomatoes. While healthy, salad greens with tomatoes do not provide sufficient protein to replace a hamburger.
D. Roasted turkey sandwich. Turkey is a lean protein source with much lower saturated fat content compared to a hamburger, making it an excellent alternative.
Correct Answer is ["539"]
Explanation
- 6 ounces of apple juice = 177 mL (1 ounce = 29.57 mL)
- 1 cup of water = 240 mL (1 cup = 240 mL)
- 1 cup of soup = 240 mL
- 6 ounces of tea = 177 mL
- 12 ounces of carbonated beverage = 355 mL
Total intake: 177 + 240 + 240 + 177 + 355 = 1189 mL
Total output:
- Voided at 0830 = 250 mL
- Vomitus at 1300 = 150 mL
- Voided at 1400 = 250 mL
Total output: 250 + 150 + 250 = 650 mL
Fluid balance: Total intake - Total output = 1189 - 650 = 539 mL
Therefore, the client's current fluid balance is 539 mL.
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