A nurse is caring for a client in the clinic who reports an inability to drain their bladder and urgency with urination. The client's medical history indicates they have had benign prostatic hypertrophy (BPH) for the last 26 years. Which of the following other clinical manifestations of BPH will the client most likely report to the nurse? (Select all that apply.)

Pain with urination

Urination at night

Swelling around the eyes

Difficulty getting the urine stream started

Answer and Explanation

Correct Answer : B,D

A. Pain with urination: Pain during urination is not typically a common symptom of BPH. It's more commonly associated with urinary tract infections (UTIs) rather than solely due to BPH.

B. Urination at night: Frequent urination, especially at night (nocturia), is a common symptom of BPH. As the prostate enlarges, it can obstruct the urethra, leading to incomplete emptying of the bladder, and causing increased urination, especially during the night.

C. Swelling around the eyes: Swelling around the eyes is not a direct symptom of BPH. It's more commonly related to other conditions like allergies or fluid retention but not specifically associated with BPH.

D. Difficulty getting the urine stream started: This is a hallmark symptom of BPH. Enlargement of the prostate can obstruct the urethra, leading to difficulty initiating urination or a weak urine stream.

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Correct Answer is ["C","D"]

Explanation

a.Weight monitoring is important for managing fluid balance. However, daily weight checks are typically recommended for clients on dialysis to accurately monitor fluid changes and detect any issues early. Weighing oneself every other day might not provide sufficient information for managing fluid status effectively.

b.This approach is not ideal. Diuretics should be taken as prescribed by the healthcare provider, not based on subjective symptoms like puffiness of the feet. Adhering to the prescribed medication schedule is crucial for managing fluid balance.

c.This statement indicates a good understanding of fluid restriction guidelines. Following the prescribed fluid intake limits is essential for maintaining proper fluid balance and preventing complications.

d.Shortness of breath can be a sign of fluid overload or other complications, and it is important to seek medical advice promptly. Calling the doctor in such situations shows an understanding of when to seek help.

A. Discard residual gastric contents B. Test the PH of gastric aspirate. C. Auscultate sounds D. Warm the formula to body temperature E. Check the tube's placement and patency.

Correct Answer is ["B","E"]

Explanation

Correct Actions:

B. Test the pH of gastric aspirate.

Explanation: Testing the pH of gastric aspirate helps confirm that the NG tube is correctly positioned in the stomach. A pH of 4 or less generally indicates gastric placement. This step is crucial to avoid complications like aspiration and ensure proper feeding.

E. Check the tube's placement and patency.

Explanation: Ensuring that the tube is correctly positioned and patent (not blocked) is essential before administering feedings. This involves aspirating some of the gastric contents to confirm placement and flushing the tube with water to verify it is clear and functioning properly.

Incorrect Actions:

A. Discard residual gastric contents.

Explanation: While it is important to measure gastric residuals to assess the stomach's ability to handle the feeding, residuals are not discarded. Instead, they are measured and then returned to the stomach unless otherwise specified by the healthcare provider.

C. Auscultate sounds.

Explanation: Auscultation of bowel sounds is not typically required immediately before administering enteral feedings. However, assessing bowel sounds periodically can be part of overall monitoring to ensure proper gastrointestinal function.

D. Warm the formula to body temperature.

Explanation: Enteral feeding formulas are generally administered at room temperature, although some facilities may have specific protocols for warming. Most guidelines do not require warming formula to body temperature.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the discharge teaching for a client on home intermittent peritoneal dialysis. Which of the following statements by the client indicates an understanding of fluid balance self-management? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG Tube Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply)

Correct Answer is ["B","E"]

Explanation

A nurse is assigned care of a client who has HIV. Which of the following infection control precautions should the nurse plan to use while caring this client?

A nurse on the dialysis unit is caring for a client who has end-stage kidney disease and is getting ready for their first hemodialysis session. Which of the following topics should the nurse include when discussing the impact of hemodialysis treatment on the client's life? (Select all that apply.)

A nurse collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

A nurse is collecting data on a client who has had diarrhea for several days. Which of the following findings should the nurse expect?

A nurse is caring for a group of clients, who all are incontinent of urine, on the medical-surgical unit. Which comorbidities should the nurse expect to find in their medical records? (Select all that apply.)

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of following actions indicates that the AP understands the principles of infection control?

An LPN is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration. Select all that apply.