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.

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Correct Answer is C

Explanation

The patient with primary hyperparathyroidism has high levels of calcium in the blood (hypercalcemia) which can lead to symptoms such as kidney stones, bone pain, and weakness. High urine calcium levels may also be present due to the increased calcium in the blood.

One important intervention for managing hypercalcemia is to encourage ﬂuid intake to promote increased urine output and prevent the formation of kidney stones. Therefore, the nurse should encourage the patient to drink at least 4000 ml of ﬂuids per day.

Seizure precautions (a), range-of-motion exercises (b), and monitoring for positive Chvostek’s or Trousseaus sign (d) are not directly related to managing hypercalcemia and are not necessary in this case.

A. I should weigh myself daily and report any sudden weight loss or gain." B. I need to limit my ﬂuid intake to no more than 1 quart of liquids a day," C. I will eat foods high in potassium because the diuretics cause potassium loss.” D. I need to shop for foods that are low in sodium and avoid adding salt to foods.

Correct Answer is C

Explanation

The correct answer is c. I will eat foods high in potassium because the diuretics cause potassium loss.

Rationale for Choice A:

Statement:"I should weigh myself daily and report any sudden weight loss or gain."
Rationale:This statement is correct.It's crucial for patients with SIADH to monitor their weight daily as even slight fluctuations can signal fluid imbalances.Sudden weight gain can indicate fluid retention,while sudden weight loss might suggest dehydration.Both scenarios warrant medical attention.

Rationale for Choice B:

Statement:"I need to limit my fluid intake to no more than 1 quart of liquids a day."
Rationale:This statement is also correct.Fluid restriction is a cornerstone of SIADH management.By limiting fluid intake,patients can help prevent the buildup of excess fluid in the body,which can lead to complications such as hyponatremia (low sodium levels in the blood) and edema.

Rationale for Choice C:

Statement:"I will eat foods high in potassium because the diuretics cause potassium loss."
Rationale:This statement is incorrect.While some diuretics used in the treatment of SIADH can indeed cause potassium loss,this is not a universal side effect.Furthermore,increasing potassium intake without medical supervision can be dangerous,potentially leading to hyperkalemia (high potassium levels in the blood).It's essential for patients to consult with their healthcare providers for individualized guidance on potassium intake.

Rationale for Choice D:

Statement:"I need to shop for foods that are low in sodium and avoid adding salt to foods."
Rationale:This statement is correct.A low-sodium diet is often recommended for patients with SIADH to help manage fluid balance and prevent hyponatremia.Restricting sodium intake can reduce fluid retention and help maintain appropriate sodium levels in the blood.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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