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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Correct Answer is D

Explanation

A. Decreased serum sodium: Kayexalate exchanges sodium for potassium, so sodium may actually increase.

B. Decreased serum phosphorus: Kayexalate does not directly affect phosphate levels.

C. Decreased urine specific gravity: Kayexalate does not influence urine output or concentration.

D. Decreased serum potassium: Kayexalate treats hyperkalemia by exchanging potassium ions for sodium in the intestines, lowering serum potassium.

A. Blistering of area B. Dry crusting surface C. Intact skin surface D. Blanching of wound area E. Pain at wound site

Correct Answer is ["A","D","E"]

Explanation

A. Blistering of area: Blisters are characteristic of superficial partial-thickness burns, involving the epidermis and part of the dermis.

B. Dry crusting surface: This is more typical of deeper burns; partial-thickness burns are moist.

C. Intact skin surface: The skin is not intact; it is damaged and blistered.

D. Blanching of wound area: Indicates intact capillary refill and superficial depth.

E. Pain at wound site: Nerve endings are exposed, making these burns very painful.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving sodium polystyrene sulfonate (Kayexalate) for the treatment of chronic renal disease. The nurse should monitor for which therapeutic effect of sodium polystyrene sulfonate (Kayexalate)?

Correct Answer is D

Explanation

A child has presented to the ER after a burn injury from a hot soup spill. Exhibits A nurse is caring for a preschooler diagnosed with a superficial partial- thickness burn on the right forearm. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

Patient presented for follow up of major burn injury. Exhibits A nurse is caring for a client recovering for 12 months from major burns that affected 60% total body surface area (TBSA). Which of the following complications should the nurse expect? (Select all that apply)

A nurse is assessing a client diagnosed with end-stage renal disease (ESRD) that is receiving hemodialysis. Which of the following findings should the nurse identify as an indication that the client is experiencing fluid overload?

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. The nurse recognizes that which pain management strategy should best meet this client's pain control needs?

A nurse is conducting an assessment of a client with a severe circumferential burn injury to the forearm. Which of the following assessments should the nurse prioritize? (Select All that Apply.)

A nurse in an emergency room is caring for a client who sustained deep partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

A nurse is preparing to care for a client after a full thickness chemical burn of the bilateral lower extremities. The nurse is aware that 3rd degree, full thickness burns affect which of the following? Select all that apply.

A nurse is caring for a client experiencing fatigue secondary to anemia from chronic kidney disease (CKD). How should the nurse respond when the client asks about the cause of the anemia symptoms they are experiencing?