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 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.
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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