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

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Urinary Tract Infection (UTI)
The client is reporting frequency, burning, and urgency, classic symptoms of a lower UTI (cystitis). The recent removal of the urinary catheter (which increases infection risk) further supports this.

Actions to take:

Check a urine culture and sensitivity: A urine culture will confirm the presence of infection and identify the specific organism, allowing for appropriate antibiotic selection.
Request a prescription for an antispasmodic agent: Bladder spasms can contribute to frequency and urgency, especially post-catheter removal. An antispasmodic (e.g., oxybutynin) may help relieve discomfort.

Parameters to monitor:

Temperature: Fever can indicate progression of the UTI to pyelonephritis or worsening infection. The current low-grade fever of 100.4°F may be an early sign.
Fluid intake: Adequate hydration helps flush bacteria from the urinary tract and is essential in promoting recovery from a UTI.

Incorrect diagnoses:

The post-void residual is only 22 mL, which rules out urinary retention. No evidence points to STIs like gonorrhea, nor to incontinence.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Formula: 4 mL × Body weight (kg) × %TBSA

4 × 100 × 40 = 16,000 mL total in 24 hours

Half (8,000 mL) is given in the first 8 hours

Answer- 8000ml

A. Obtain a complete blood count (CBC) B. Start IV fluids C. Apply direct pressure D. Administer pain medication

Correct Answer is C

Explanation

A. Obtain a complete blood count (CBC): This is not the immediate action in an active bleeding scenario.

B. Start IV fluids: This may be needed later if significant blood loss occurs, but not the first response.

C. Apply direct pressure: Bleeding from a fistula requires immediate direct pressure to prevent blood loss and preserve vascular access.

D. Administer pain medication: Pain management is important but not the priority in acute bleeding.

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Naxlex Comprehensive Predictor Exams

A nurse is monitoring the fluid replacement of a client who has sustained burns over 40% total body surface area (TBSA). The client weight is 100kg According to the Parkland Formula, how much fluid will the client require in the first 8 hours?

Correct Answer is D

Explanation

A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

Correct Answer is C

Explanation

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