You note the following findings on your patient: (see chart below)

Vital Signs

Blood Pressure: 138/84

Heart Rate: 98 beats per minute

Respiratory Rate: 18 breaths per minute

Temperature: 99.6F

Pulse oximetry: 97% on room air

Pain: 7/10

Intake and output

Intake for past 12 hours: 2150mL

Output for past 12 hours: 150mL

Meals: 100% breakfast 75% lunch 90% dinner

Based on these findings, what intervention should you implement first?

Check the patient's urinalysis.

Notify the provider of the patient's pain 7/10

Perform a bladder scan

Assess the daily weight.

Answer and Explanation

The Correct Answer is C

A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.

B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.

C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.

D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Better Clinical Outcomes: Meaningful Use ensures that healthcare providers adopt EHRs to improve quality, safety, and efficiency in patient care, leading to better treatment decisions and improved outcomes. Increased Transparency and Efficiency: EHRs promote real-time data sharing and streamlined workflows, reducing errors and redundant tests while enhancing communication between providers. Empowered Individuals: Patients have better access to their health records, leading to increased engagement, self-management of conditions, and informed decision-making.

B. More Robust Research Data on Health Systems: While EHR data can be used for research, this is not a direct goal of Meaningful Use. Improve Safety: This is a correct statement, but "Decrease Functionality" contradicts the purpose of Meaningful Use. Decrease Functionality: Meaningful Use aims to enhance, not reduce, the functionality of EHR systems.

C. Improved Population Health Outcomes: This is a correct benefit of Meaningful Use, as data-driven approaches help manage public health issues more effectively. Complicate Care Coordination: This is incorrect because Meaningful Use promotes interoperability, which enhances rather than complicates coordination. Interoperability: While interoperability is a goal of meaningful Use, this option presents a mix of correct and incorrect statements.

D. Improved Population Health Outcomes: This is a correct benefit of Meaningful Use. Increase Health Disparities: This is incorrect because Meaningful Use is designed to reduce disparities by improving access to digital health records and quality care. Engage Patients and Families: This is a correct statement, as patient portals and EHR access encourage active participation in health management. However, the inclusion of "Increase Health Disparities" makes this answer incorrect.

A. It is painful to sit on a bedpan. B. The position encourages the Valsalva maneuver. C. The position does not facilitate downward pressure. D. The cause is unknown and requires further study.

Correct Answer is C

Explanation

A. It is painful to sit on a bedpan. Discomfort may be a factor, but pain alone does not explain the difficulty in having a bowel movement.
B. The position encourages the Valsalva maneuver. The Valsalva maneuver (straining against a closed airway) can occur in any position, but posture is the primary problem here.
C. The position does not facilitate downward pressure. The seated position allows for gravity and proper abdominal muscle engagement, making defecation easier. Lying down does not facilitate intra-abdominal pressure.
D. The cause is unknown and requires further study. The relationship between position and defecation is well understood in physiology.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What are three positive results of meaningful use compliance in the Electronic Health Record?

Correct Answer is A

Explanation

A client is having difficulty having a bowel movement laying on the bedpan. What is the physiologic reason for this problem?

Correct Answer is C

Explanation

The nurse is providing oral care to a sedated patient. What intervention is most important to implement with this patient?

The following procedures have been ordered and implemented for a hospitalized patient. Which procedure carries the greatest risk for a healthcare-associated infection?

A patient has called the nurse to help them ambulate to the bathroom. The nurse assists the patient to a dangling position on the bed and applied the gait belt. Upon standing, the patient reports that they are feeling very dizzy. What is the next best action by the nurse?

A client is on bed rest and an enema has been ordered. In what position should the nurse position the client?

A nurse is admitting a client to a geriatric medicine unit. Which action would the nurse implement to reduce the clients risk for falling?

You are providing care for a patient on a clear liquid diet. You know your teaching about the clear liquid diet has been effective when the patient chooses which of the following meals?

A nurse is providing education to a female patient who has been diagnosed with recurrent urinary tract infections. What statement should the nurse include in the education?