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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Let me teach you about antibiotics and their usage." This response provides education about antibiotics, including why they are not effective against viral infections. It acknowledges the client’s frustration while promoting understanding.

B. "Let me talk to the provider and see what we can do." This response suggests that the nurse might override the provider’s decision or negotiate an unnecessary prescription, which is inappropriate.

C. "Why do you think you need an antibiotic?" While this question encourages the client to express their thoughts, it may come across as dismissive or challenging rather than supportive.

D. "I understand your frustration. You need an antibiotic." This statement is incorrect because it reinforces a misconception that antibiotics are needed for viral infections, which can contribute to antibiotic resistance.

A. "Everyone knows there are others who can chair this committee better than me." B. "It's just not the right time for me to do this." C. “I decline the opportunity at this time.” D. "Can you tell me why you chose me?"

Correct Answer is C

Explanation

A. "Everyone knows there are others who can chair this committee better than me." This statement is self-deprecating and does not reflect assertive communication. It shifts responsibility to others instead of setting a clear boundary.

B. "It's just not the right time for me to do this." While this statement declines the opportunity, it leaves room for misinterpretation and follow-up pressure to accept later.

C. "I decline the opportunity at this time." This is a clear, direct, and assertive way to decline without over-explaining or inviting negotiation.

D. "Can you tell me why you chose me?" This response does not decline the role; instead, it invites discussion and may make it harder to say no later.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a viral upper respiratory infection tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse?

Correct Answer is A

Explanation

A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Which of the following statements would be best for the nurse to make?

Correct Answer is C

Explanation

After applying pneumatic compression devices to bilateral lower extremities on a patient who is on bedrest, the patient asks what the purpose is of the device. How should the nurse respond to best address the patient's question?

The nurse is providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?

The student nurse has identified that the patient is a risk for falling and has implemented fall precautions. What action taken by the student would require further teaching from the clinical faculty?

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?

The nurse is providing care for the following patients. Which patient is at highest risk of developing an infection?

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?

Order: Ampicillin 1000 mg PO every 12 hours Available: Ampicillin 250 mg capsules How many capsules will you administer per day?