A nurse is assisting with the care of a client in a medical-surgical unit.
Vital Signs
05:00
Temperature 36.6 C (97.9 F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 160/98 mm Hg
Oxygen saturation 96% on oxygen 2 L/min via nasal cannula
14:00
Temperature 36.8 C (98.3 F)
Heart rate 90/min
Respiratory rate 18/min
Blood pressure 138/88 mm Hg
Oxygen saturation 97% on oxygen 2 L/min via nasal cannula
Which of the following actions should the nurse take to decrease the risks for a urinary tract infection for this client? Select all that apply.
Encourage the client to drink 3,000 mL of fluid daily.
Change the indwelling urinary catheter tubing every 3 days.
Place the drainage bag on the bed when transporting the client.
Empty the drainage bag when it is half-full.
Review the need for the indwelling urinary catheter daily.
Use soap and water to provide perineal care.
Correct Answer : A,D,E,F
To decrease the risks for a urinary tract infection for this client, the nurse should take several actions. The nurse should encourage the client to drink 3,000 mL of fluid daily to help flush bacteria out of the urinary tract¹. The nurse should also empty the drainage bag when it is half-full to prevent bacterial growth¹.
Additionally, the nurse should review the need for the indwelling urinary catheter daily and use soap and water to provide perineal care¹.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
It is important for the client to remain still during the recording of a 12-lead ECG to obtain accurate and clear readings of the heart's electrical activity.
The orthopneic position (sitting upright and leaning forward) is typically used to help relieve shortness of breath in clients with respiratory distress and is not directly related to obtaining a 12-lead ECG.
Attaching a blood pressure cuff is not necessary for obtaining a 12-lead ECG, as it measures blood pressure and not the electrical activity of the heart.
A mild stinging sensation is not expected during the test. The electrodes used to record the ECG are typically adhesive and do not cause discomfort to the client
Correct Answer is A
Explanation
A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. The nurse should choose a room that is well-lit, sit facing the client, speak clearly and slowly, and ask a few questions at a time. Exaggerating lip movement while speaking is not recommended as it can be difficult for the client to read lips accurately. Additionally, sitting on the client's right side may not make a significant difference in their ability to hear.
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