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 A

Explanation

This meal choice is low in sodium as it contains fresh ingredients and does not include processed or pre-packaged foods that are typically high in sodium. Chicken, bread, and carrots are naturally low in sodium, and the client can control the amount of added salt or seasoning. In contrast, the other food choices are likely to be high in sodium due to added salt, cheese, or processed ingredients.

Therefore, the nurse should encourage the client to choose fresh, low-sodium foods and avoid processed or pre-packaged meals.

A. Teach the patient how to perform Kegel exercises. B. Assist the patient to the bathroom q3hr. C. Demonstrate how to perform Crede’s maneuver. D. Place commode at the patient’s bedside.

Correct Answer is A

Explanation

Kegel exercises are designed to strengthen the pelvic ﬂoor muscles, which can help improve urinary incontinence. By teaching the patient how to perform Kegel exercises, the nurse can provide a non-invasive, eﬀective intervention that the patient can perform on her own to help manage her urinary incontinence.

Assisting the patient to the bathroom q3hr (b) may help reduce the frequency of incontinence episodes but it does not address the underlying issue of weakened pelvic ﬂoor muscles.

Demonstrating how to perform Crede’s maneuver (c) involves applying manual pressure to the bladder to assist with urination and is not appropriate for managing urinary incontinence related to laughing or coughing.

Placing a commode at the patient’s bedside (d) may be appropriate for patients who have difficulty with mobility or accessing the bathroom, but it does not address the underlying issue of weakened pelvic ﬂoor muscles causing urinary incontinence.

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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 A

Explanation

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Correct Answer is A

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