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

NSAIDs are known to be a common cause of acute gastritis. Therefore, it is essential for the nurse to ask the patient about their frequency of NSAID use to determine if this may have caused their current symptoms. Other options such as family history of gastric problems, recent weight gain or loss, and amount of fat in the diet, may also be relevant to the patient's overall health status, but they are not as important as the potential cause of their current condition.

A. The patient has a urine output of 800 ml/hr. B. The patient is confused and lethargic. C. The patient's urine specific gravity is 1.003. D. The patient had a recent head injury.

Correct Answer is B

Explanation

Diabetes insipidus is a condition where the body is not able to regulate water balance properly, leading to excessive urine output and dehydration. The patient's urine output of 800 ml/hr (option A) and low urine specific gravity of 1.003 (option C) is consistent with diabetes insipidus and requires monitoring, but they are not as immediately concerning as the patient's confusion and lethargy.

Confusion and lethargy may indicate severe dehydration, electrolyte imbalances, or even brain swelling (if the patient had a recent head injury, as mentioned in option D). These symptoms require immediate attention to prevent further complications and ensure the patient's safety.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is admitting a patient who is nauseated and vomiting up blood-streaked ﬂuid with diagnosis of acute gastritis. When obtaining the admission health history, it will be most important for the nurse to ask the patient about:

Correct Answer is A

Explanation

Which of the information below obtained when caring for a patient who has been admited for evaluation of diabetes insipidus will be of greatest concern to the nurse?

Correct Answer is B

Explanation

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