A nurse is caring for a client in the medical-surgical unit.

Exhibits

Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client?
Select all that apply.

Use soap and water to provide perineal care.

Change the indwelling urinary catheter tubing every 3 days

Encourage the client to drink 3000 ml of fluid daily.

Review the need for the indwelling urinary catheter daily

Place the drainage beg on the bed when transporting the client

Answer and Explanation

Correct Answer : A,D,E

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Correct Answer is D

Explanation

Choice A rationale:

An increase in heart rate by 10 beats per minute when moving from a supine to a sitting position is a normal physiological response to compensate for decreased venous return and maintain cardiac output. This response does not indicate orthostatic hypotension.

Choice B rationale:

An increase in diastolic blood pressure by 10 mm Hg when moving from a supine to a sitting position is a normal response to compensate for the effects of gravity on blood flow. It helps maintain perfusion to vital organs and does not indicate orthostatic hypotension.

Choice C rationale:

Heart palpitations can occur due to various reasons, including anxiety or arrhythmias, but they are not specific signs of orthostatic hypotension. This symptom alone does not confirm the presence of orthostatic hypotension.

Choice D rationale:

A decrease in systolic blood pressure by 25 mm Hg or more when moving from a supine to a sitting position indicates orthostatic hypotension. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more or a drop in diastolic blood pressure of 10 mm Hg or more within 3 minutes of standing up. This condition can cause dizziness, lightheadedness, or fainting and can be a side effect of antihypertensive medications or other underlying medical conditions.

A. INR B. Fibrinogen level C. aPTT D. Platelet count

Correct Answer is A

Explanation

A. Correct. The International Normalized Ratio (INR) is used to monitor the effectiveness of warfarin therapy, which is commonly prescribed to prevent blood clotting. The INR provides information about the client's prothrombin time (PT) in relation to a standardized value.
B. Fibrinogen level measures clotting potential but is not directly related to warfarin therapy monitoring.
C. Activated Partial Thromboplastin Time (aPTT) is used to monitor other anticoagulants like heparin, not warfarin.
D. Platelet count measures the number of platelets in the blood and is not specifically related to warfarin therapy monitoring.

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A nurse is caring for a client in the medical-surgical unit. Exhibits Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position.Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

Correct Answer is D

Explanation

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

Correct Answer is A

Explanation

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A nurse is caring for a client in the medical-surgical unit.

Exhibits

Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client?
Select all that apply.