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 A
Explanation
The correct answer is: a. Temperature 38.8° C (101.8° F)
Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.
Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.
Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.
Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.
Correct Answer is D
Explanation
Encouraging the client to be assertive is an important aspect of managing dependent personality disorder. It helps the client develop self-confidence, make independent decisions, and advocate for their own needs.
Empowering the client to express their opinions and assert their boundaries can contribute to their personal growth and reduce their reliance on others.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today