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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The pH value is less than the normal range of 7.35-7.45, indicating acidosis. The PaCO2 value is elevated above the normal range of 35-45 mmHg, indicating respiratory acidosis. The PaO2 value is lower than normal, but not significantly low enough to indicate hypoxemia. The HCO3- level is within the normal range, but not significantly high enough to indicate metabolic compensation for respiratory acidosis.
Correct Answer is B
Explanation
The statement "I had the stomach flu earlier this week and couldn't take the hydrocortisone" indicates that the patient may not be adhering to their prescribed medication regimen, which can lead to an Addisonian crisis. Therefore, the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge of management of the condition is appropriate.
Addison’s disease is a condition in which the adrenal glands do not produce enough cortisol and aldosterone. Hydrocortisone is a glucocorticoid medication that is often used to replace the cortisol that the adrenal glands are not producing. In the Addisonian crisis, the body is unable to produce the necessary levels of cortisol and aldosterone, which can lead to potentially life-threatening complications such as hypotension, dehydration, and electrolyte imbalances.
The other statements may indicate areas where patient education is needed, but they do not directly relate to the immediate risk of an Addisonian crisis.
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