A nurse is caring for a client in the medical-surgical unit. l&O.
1900:
750 mL intake over 12 hr.
650 mL urine output over 12 hr.
Admission Assessment.
0500:
Client admitted from emergency department with heart failure Crackles auscultated bilaterally throughout lung fields.
Lower extremities cool and dry with 1 + pedal pulses and 3+ pitting edema bilaterally.
Capillary refill 2 seconds.
0800:
Client is incontinent of urine.
Vital Signs.
0500:
Temperature 36.6° C (97.9° F).
Heart rate 100/min.
Respiratory rate 22/min.
BP 160/98 mm Hg.
Pulse oximetry 96% on oxygen 2 L/min via nasal cannula.
1400:
Temperature 36.8° C (98.2° F).
Heart rate 90/min.
Respiratory rate 18/min.
BP 138/88 mm Hg.
Pulse oximetry 97% on oxygen 2 L/min via nasal cannula.
Provider Prescriptions.
0500:.
Administer oxygen 2 L/min via nasal cannula.
Monitor intake and output.
Fluid restriction of 1000 mL daily.
1000:.
Insert indwelling urinary catheter.
Laboratory Results.
0600:.
Calcium 9.3 mg/dL (9.0 to 10.5 mg/dL). Chloride 105 mEq/L (98 to 106 mEq/L).
Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L).
Phosphate 4.1 mg/dL (3 to 4.5 mg/dL).
Potassium 4.5 mEq/L (3.5 to 5.0 mEq/L) Sodium 149 mEq/L (136 to 145 mEq/L).
Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client?
Select all that apply.
Review the need for the indwelling urinary catheter daily.
Place the drainage bag on the bed when transporting the client.
Use soap and water to provide perineal care.
Encourage the client to drink 3000 mL of fluid daily.
Change the indwelling urinary catheter tubing every 3 days.
Empty the drainage bag when it is half-full.
Correct Answer : A,C
A: Review the need for the indwelling urinary catheter daily.
This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).
B: Place the drainage bag on the bed when transporting the client.
This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent the backflow of urine and contamination of the catheter.
C: Use soap and water to provide perineal care.
This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.
D: Encourage the client to drink 3000 mL of fluid daily.
This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.
E: Change the indwelling urinary catheter tubing every 3 days.
This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.
F: Empty the drainage bag when it is half full.
This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is d. Evaluate functioning of the suction device.
Choice D rationale:
- Prompt assessment of the suction device is crucial to determine if it's functioning properly.If the suction is inadequate,it can lead to gastric contents accumulating and potentially causing vomiting.
- Assessing the suction device first allows for timely interventionif it's not working correctly,preventing further complications and discomfort for the client.
Choice A rationale:
- Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
- Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.
Choice B rationale:
- Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
- Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.
Choice C rationale:
- Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
- Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.
Correct Answer is C
Explanation
- . Answer and explanation.
The correct answer is choice C, first-degree atrioventricular block.
This is because the PR interval is longer than normal, which indicates a delay in the conduction of electrical impulses from the atria to the ventricles through the AV node. A normal PR interval is 0.12 to 0.2 seconds, or 3 to 5 small squares on the EKG strip.
In this case, the PR interval is 0.35 seconds, which is more than 5 small squares.
Choice A is wrong because atrial fibrillation is a type of arrhythmia where the atria beat irregularly and rapidly, producing chaotic and variable P waves and an irregular ventricular response.
There is no constant PR interval in atrial fibrillation.
Choice B is wrong because complete heart block is a type of arrhythmia where there is no conduction of electrical impulses from the atria to the ventricles, resulting in independent and dissociated atrial and ventricular rhythms.
There are no consistent P waves or PR intervals in complete heart block.
Choice D is wrong because premature atrial complexes are extra beats that originate from the atria and interrupt the normal sinus rhythm.
They produce abnormal P waves that are different from the sinus P waves, and may have a shorter or longer PR interval depending on the timing of the impulse.
However, they do not cause a constant prolongation of the PR interval.
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