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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

When caring for a client with paranoid schizophrenia who has delusions or beliefs that are not based in reality, it is important to respond in a therapeutic and empathetic manner. Acknowledging the client's fear and validating their experience can help establish trust and promote open communication.

The response "This must be very frightening for you. Let's talk more about it" demonstrates empathy and a willingness to engage in further discussion, allowing the client to express their concerns and facilitating a therapeutic relationship.

A. A client who had a renal biopsy 3 hr ago and has pink-tinged urine B. A client who has a femur fracture and reports numbness of the toes C. A client who has cirrhosis and severe pruritus D. A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge

Correct Answer is B

Explanation

Numbness of the toes in a client with a femur fracture may indicate neurovascular compromise, which requires immediate attention.

It could be a sign of impaired circulation or nerve damage, and prompt assessment is needed to prevent further complications or permanent damage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?

Correct Answer is B

Explanation

A nurse is caring for a client who has anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective?

A nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory tests should the nurse monitor?

A nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following responses should the nurse make?

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?

A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement first?