A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first?

Schedule for IVP.

Draw blood for blood urea nitrogen (BUN) and creatinine.

Insert 16 French retention catheter.

Administer lorazepam (Ativan) 0.5 mg.

Answer and Explanation

The Correct Answer is C

The nurse should act on the order to insert a 16 French retention catheter first. The patient's markedly distended bladder and agitated and confused state suggest acute urinary retention, which can be relieved by inserting a catheter to drain the urine. This is a priority intervention as urinary retention can lead to serious complications such as bladder rupture, hydronephrosis, and renal failure. Once the catheter is inserted and the patient's bladder is drained, the healthcare provider can order further tests such as an IVP or blood tests to assess renal function. The order for lorazepam can be addressed after the catheter is inserted and the patient's urinary retention is addressed.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The patient has been diagnosed with type 2 diabetes and reports following a reduced-calorie diet but has not lost any weight. This suggests that the patient may not be following the diet as prescribed or may have other factors aﬀecting their blood glucose levels. Additionally, the patient did not bring their glucose monitoring record, which is an important tool for assessing blood glucose control over time.

In this situation, obtaining a fasting blood glucose level or an oral glucose tolerance test may provide a snapshot of the patient's blood glucose level at the time of the test, but these tests do not provide information about blood glucose control over the past few months. A urine dipstick for glucose is a less reliable method for assessing blood glucose control and is not recommended for routine monitoring.

Therefore, obtaining a glycosylated hemoglobin (HbA1c) level is the most appropriate test in this situation. HbA1c reﬂects the average blood glucose level over the past 2-3 months and is recommended for routine monitoring of blood glucose control in patients with diabetes. This test can provide valuable information about the eﬀectiveness of the patient's diet and any other interventions aimed at controlling their blood glucose levels.

A. Provide three large meals a day. B. Observe stool characteristics. C. Evaluate intake and output. D. Monitor laboratory reports of electrolytes.

Correct Answer is A

Explanation

Clients with acute gastritis are recommended to eat smaller, frequent meals instead of three large meals. This helps to reduce the workload on the digestive system and allows the stomach to heal. Therefore, option A is not a suitable nursing intervention for a client with acute gastritis.

Options b, c, and d are all appropriate nursing interventions for a client with acute gastritis. Observing stool characteristics can help to identify any bleeding or inﬂammation in the gastrointestinal tract, evaluating intake and output can help to identify any ﬂuid imbalances, and monitoring laboratory reports of electrolytes can help to identify any imbalances that may occur because of vomiting or diarrhea.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports following a reduced-calorie diet. The patient has not lost any weight and did not bring the glucose-monitoring record. The nurse will plan to obtain a(n)

Correct Answer is D

Explanation

A nurse is planning care for a client who has acute gastritis. Which of the following nursing interventions should NOT be included in the plan of care?

Correct Answer is A

Explanation

The nurse is creating the care plan for a patient with symptoms of DI who was admited to the hospital for evaluation and treatment of the condition. An appropriate nursing diagnosis for the patient is:

The nurse is caring for a patient with hypothermia and ﬂuid volume excess. Which of the following would be included in the plan of care?

When admitting a patient with a stroke who is unconscious and unresponsive to stimuli. The nurse learns from the patient’s family that the patient has a history of GERD, the nurse will plan to do frequent assessment of the patient’s:

Cardiac monitoring is initiated for a patient with diabetic ketoacidosis. The nurse determines that this measure is important to identify:

A program of weight loss and exercise is recommended for a patient with impaired fasting glucose (IFG). When teaching the patient about the reason for these lifestyle changes, the nurse will tell the patient that:

A patient who is hospitalized with abdominal pain and watery, incontinent diarrhea is diagnosed with Clostridium difficile. In planning care for the patient, the nurse will:

Mary, a 63-year-old patient is newly diagnosed with type 2 diabetes. When determining an education plan, the nurse’s first action should be to?

During the nursing assessment of a patient with Graves' disease. The nurse notes a bounding, rapid pulse and systolic hypertension. Based on these assessment data, which question is important for the nurse to ask the patient?