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 C
Explanation
Sponge baths are recommended until the umbilical cord stump falls off, which typically occurs within the first two weeks of life. After that, the baby can be immersed in water for a regular bath. Using talcum powder is not recommended as it can be harmful to the baby's respiratory system if inhaled. Mild, pH-balanced soap should be used instead of alkaline soap to avoid irritating the baby's delicate skin. The bathwater temperature should be around 98 degrees Fahrenheit and not hoter than 100 degrees Fahrenheit to prevent burns.
Correct Answer is B
Explanation
Before any invasive procedure, it is essential to ensure that the client has provided informed consent. Informed consent involves providing the client with information about the procedure, its risks, benefits, and alternatives, allowing them to make an informed decision about their healthcare. The nurse should verify that the client has been adequately informed about the esophagogastroduodenoscopy procedure and has given consent before proceeding.
Informing the client about the procedure duration of 60 minutes is not a priority action. While it is helpful to provide the client with information about the procedure, the specific duration of the procedure may vary depending on various factors, and it does not require immediate attention prior to the procedure.
Ensuring that the client's bladder is full is not necessary for an esophagogastroduodenoscopy procedure. The procedure involves examining the upper gastrointestinal tract and does not involve the bladder or urinary system.
Administering an oral contrast solution is not typically required for an esophagogastroduodenoscopy procedure. Oral contrast solutions are commonly used for other
diagnostic imaging procedures, such as computed tomography (CT) scans or barium studies, but not for esophagogastroduodenoscopy.
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