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 nurse should identify the sudden increase in energy as the priority finding to report to the provider. This could be a sign of an emerging manic episode, especially if the client is taking an antidepressant alone without a mood stabilizer.
It may indicate a switch to a manic state or the development of bipolar disorder. The provider needs to be informed promptly so that appropriate assessment and interventions can be implemented to ensure the client's safety and well-being.
Correct Answer is C
Explanation
Children often have difficulty understanding the complex nature of illness and death. They may develop feelings of guilt or responsibility for the situation, thinking that their behavior or actions caused the illness or its outcome.
It is important for the nurse to provide support, reassurance, and age-appropriate explanations to address the sibling's concerns and misconceptions.
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