A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?" Which action should the practical nurse (PN) implement?

Catheterize the client for residual urine volume

Measure the next voiding, then palpate the client's bladder

Evaluate for normal involution, then massage the fundus

Obtain a specimen for urine culture and sensitivity

Answer and Explanation

The Correct Answer is B

Urinary output is an important indicator of ﬂuid balance and kidney function. After delivery, a woman may experience increased urinary output due to the loss of excess ﬂuid that was retained during pregnancy and the diuretic eﬀect of oxytocin, which is released during breastfeeding. This is a normal and expected finding in the postpartum period.
However, increased urinary output may also be a sign of urinary retention, which is the inability to empty the bladder completely. Urinary retention can occur due to trauma to the bladder or urethra during delivery, swelling or hematoma of the perineum, epidural anesthesia, or decreased bladder sensation.Urinary retention can lead to complications such as infection, bladder distension, or postpartum hemorrhage.
Therefore, when a woman who delivered a normal newborn 24 hours ago reports that she seems to be urinating every hour or so, the practical nurse (PN) should measure the next voiding, then palpate the client's bladder. This will help to assess the amount and quality of urine and the presence or absence of bladder distension. A normal urine output is about 30 ml per hour, and a normal bladder should feel soft and empty after voiding. If the urine output is low or high, or if the bladder feels firm or full after voiding, the PN should report these findings to the primary healthcare provider for further evaluation and intervention.

Therefore, option B is the correct answer, while options A, C, and D are incorrect.

Option A is incorrect because catheterizing the client for residual urine volume is an invasive procedure that should only be done if indicated by the primary healthcare provider.

Option C is incorrect because evaluating for normal involution and massaging the fundus are related to uterine function, not urinary function.

Option D is incorrect because obtaining a specimen for urine culture and sensitivity is not necessary unless there are signs of infection, such as fever, dysuria, or foul-smelling urine.

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Correct Answer is B

Explanation

An antibiotic that can cause nephrotoxicity is an antibiotic that can damage the kidneys, which are the organs that filter the blood and remove waste products and excess ﬂuid from the body. Some examples of nephrotoxic antibiotics are aminoglycosides, vancomycin, amphotericin B, and sulfonamides.

Serum creatinine is a laboratory value that measures the amount of creatinine in the blood. Creatinine is a waste product that is produced by the breakdown of muscle tissue and is normally excreted by the kidneys. A high serum creatinine level indicates that the kidneys are not functioning properly and are unable to filter out the creatinine from the blood.

Before administering an antibiotic that can cause nephrotoxicity, it is important for the practical nurse (PN) to review the serum creatinine level of the client, as it reﬂects the kidney function and the risk of nephrotoxicity. A normal serum creatinine level ranges from 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women. If the serum creatinine level is elevated, it may indicate that the client has impaired kidney function or is developing nephrotoxicity from the antibiotic. In this case, the PN should notify the primary healthcare provider and monitor the client for signs and symptoms of nephrotoxicity, such as decreased urine output, edema, hypertension, or electrolyte imbalances .

A. Initiate contact precautions for the client upon admission. B. Restrict visitors from entering the client's room during hospitalization. C. Wear a surgical mask while providing care for the client. D. Have the client wear a surgical mask while being transported outside the room.

Correct Answer is D

Explanation

A. Initiate contact precautions for the client upon admission. This is incorrect because contact precautions are not sufficient to prevent the spread of TB, which is an airborne disease that can travel through small droplets in the air.

B. Restrict visitors from entering the client's room during hospitalization. This is incorrect because visitors can enter the client's room as long as they wear appropriate personal protective equipment (PPE) such as an N95 respirator, gown, gloves, and eye protection.

C. Wear a surgical mask while providing care for the client. This is incorrect because a surgical mask does not filter out small airborne particles that carry TB bacteria. The nurse should wear an N95 respirator or higher level of respiratory protection when caring for a client who has active TB.

D. Have the client wear a surgical mask while being transported outside the room. This is correct because a surgical mask can reduce the amount of droplets that are expelled by the client when coughing or sneezing, thus minimizing the risk of infecting others in common areas or hallways.

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A woman who delivered a normal newborn 24 hours ago reports, "I seem to be urinating every hour or so. Is that OK?" Which action should the practical nurse (PN) implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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