A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

Client's bladder.

Catheter tubing.

The client's bed.

Urinary meatus.

Answer and Explanation

The Correct Answer is B

A. Client's bladder: The bladder is typically sterile. Infection is most likely introduced from external sources such as the catheter or tubing.
B. Catheter tubing: The catheter and its tubing can harbor bacteria, which increases the risk of a urinary tract infection.
C. The client's bed: Although the bed should be kept clean, it is unlikely to be the direct source of infection.
D. Urinary meatus: The meatus is usually sterile, and infection is more likely to arise from the catheter or tubing.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Determine how the client is administering the medication: While the nurse should assess medication administration, jaw pain could be a sign of a serious side effect, and reporting to the healthcare provider is the priority.
B. Advise the client to gargle with warm salt water twice daily: Gargling with salt water may provide some comfort but is not an appropriate solution for jaw pain related to bisphosphonate therapy.
C. Report the client's jaw pain to the healthcare provider: Jaw pain could be a sign of osteonecrosis of the jaw, a rare but serious side effect of bisphosphonates. Immediate reporting is essential.
D. Confirm that this is a common symptom of osteoporosis: Jaw pain is not a common symptom of osteoporosis and should be assessed further.

Correct Answer is []

Explanation

Potential Condition - Tension pneumothorax:

The client presents with sudden decreased oxygen saturation (56%) after being intubated, along with absent breath sounds on the left side and a tracheal deviation to the right. These are classic signs of a tension pneumothorax, which occurs when air enters the pleural space and is trapped, leading to increased pressure on the lung and mediastinum, resulting in tracheal deviation and respiratory compromise. The low PaO2 and high PaCO2 in the ABG further support the diagnosis of respiratory failure due to this condition.

Actions to Take:

Collect equipment for a needle aspiration: Tension pneumothorax is treated emergently by needle decompression to release the trapped air and relieve the pressure on the lung and heart. The nurse should prepare for this procedure by gathering the necessary equipment.

Increase the fraction of inspired oxygen on the ventilator: Increasing the oxygen delivery can help improve the client's oxygenation while preparing for further intervention, such as needle aspiration.

Parameters to Monitor:

Blood gas: The ABG results show acid-base imbalance (low pH, elevated PaCO2, low PaO2), which need continuous monitoring to assess the effectiveness of interventions, such as needle decompression and oxygenation support.

Breath sounds: The nurse should continue auscultating for changes in breath sounds as the tension pneumothorax is treated. The resolution of the absent breath sounds on the left side would indicate the success of the intervention.

Rationale for incorrect choices:

Endotracheal tube obstruction: The absence of breath sounds on one side and the tracheal deviation suggest a pneumothorax, not an obstruction. Obstruction would typically cause wheezing or decreased breath sounds on both sides, but it wouldn’t cause tracheal deviation.

Pulmonary hypertension: Pulmonary hypertension might cause hypoxia and respiratory distress, but it would not cause the sudden and severe signs of a tension pneumothorax, such as tracheal deviation and unilateral absent breath sounds

Ventilator malfunction: While a ventilator malfunction could affect oxygenation, it would not cause the physical signs of tension pneumothorax (tracheal deviation and absent breath sounds on one side). A malfunction would likely affect the entire chest and wouldn’t cause localized changes as seen in this client.

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A client's catheter bag was left on the client's bed for a prolonged period of time, and the client develops a urinary tract infection (UTI). In evaluating the cause of the infection, which should the nurse identify as the infection reservoir?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Correct Answer is C

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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The nurse is providing a nutrition class to a group of postmenopausal clients. Which food should the nurse emphasize to this group?

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Exhibits Select from statement options to complete the sentence. To assess outcomes, the nurse should consider information reported by the client and caregiver and focus on evaluating the client's dropdown and dropdown.

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