After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

Imbalanced nutrition.

Deficient fluid volume.

Risk for infection.

Urinary incontinence.

Answer and Explanation

The Correct Answer is C

Choice A reason: Imbalanced nutrition is unrelated to 150 mL residual urine, which indicates incomplete bladder emptying, often from detrusor dysfunction or obstruction. Nutrition affects overall health but does not cause retention. Residual urine increases infection risk due to stasis, making nutrition an irrelevant nursing problem for this urinary issue.

Choice B reason: Deficient fluid volume suggests dehydration, reducing urine output, not causing high residual volumes. Residual urine (150 mL) indicates retention from impaired bladder emptying, not fluid deficit. Hydration prevents stasis, but infection risk from retained urine is more immediate, as bacteria proliferate in stagnant urine.

Choice C reason: Residual urine of 150 mL signifies incomplete bladder emptying, often from obstruction or neurogenic bladder, leading to urinary stasis. This fosters bacterial growth, increasing urinary tract infection (UTI) risk. Including “risk for infection” addresses this pathophysiological concern, guiding interventions like catheterization to reduce infection likelihood.

Choice D reason: Urinary incontinence involves involuntary leakage, not retention, where the bladder fails to empty, as seen with 150 mL residual urine. Retention results from outflow obstruction or weak detrusor, distinct from incontinence’s loss of control, making this nursing problem inappropriate for the client’s condition.

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Correct Answer is D

Explanation

Choice A reason: Ensuring oxygen and medications manages exacerbations in asthma, bronchitis, and emphysema, where airway inflammation obstructs breathing. These treat symptoms, not prevent infections. Vaccines reduce influenza and pneumococcus, major exacerbation triggers, providing specific immunity to prevent severe respiratory infections, making them a higher priority.

Choice B reason: Using tissues and handwashing reduces infection spread but is less effective than vaccines for preventing exacerbations in chronic lung diseases. Influenza and pneumococcus trigger severe bronchoconstriction or inflammation. Vaccines offer targeted protection against these pathogens, prioritizing prevention over general hygiene in high-risk clients.

Choice C reason: Avoiding crowded areas in colder months reduces viral exposure, which can exacerbate asthma or COPD via inflammation. Vaccines are more effective, providing specific immunity against influenza and pneumococcus, the most common triggers of severe exacerbations, making this less critical than vaccination for preventing respiratory complications.

Choice D reason: Annual flu and PPSV23 vaccines are critical for asthma, bronchitis, and emphysema, as these conditions increase severe infection risk. Influenza and pneumococcus trigger exacerbations via airway inflammation, risking hospitalization. Vaccines stimulate antibody production, reducing infection severity, making them the top preventive measure for chronic lung disease management.

A. Protein and albumin. B. Complete blood count (CBC). C. BUN and creatinine. D. Electrolytes.

Correct Answer is B

Explanation

Choice A reason: Protein and albumin reflect nutritional or liver status but are unaffected by enoxaparin, a low-molecular-weight heparin inhibiting factor Xa. These do not monitor anticoagulation effects or complications like bleeding. CBC is critical, as enoxaparin increases bleeding risk, requiring platelet and hemoglobin monitoring to detect serious hematological issues.

Choice B reason: Enoxaparin, an anticoagulant, heightens bleeding risk and can cause thrombocytopenia. Monitoring CBC, especially platelets and hemoglobin, detects heparin-induced thrombocytopenia (HIT) or hemorrhage. This ensures early identification of complications, allowing timely intervention to prevent severe bleeding or thrombosis, making CBC the most critical test for safe administration.

Choice C reason: BUN and creatinine assess renal function, relevant for renally cleared drugs, but enoxaparin is primarily liver-metabolized. Renal monitoring is secondary unless severe impairment exists. CBC is more urgent, as enoxaparin’s anticoagulant effect increases bleeding risk, necessitating hematological surveillance to prevent life-threatening complications.

Choice D reason: Electrolytes like potassium or sodium are not directly affected by enoxaparin’s action on the coagulation cascade. Imbalances may occur in critical illness but are not primary concerns. CBC monitoring for bleeding or thrombocytopenia is critical, as enoxaparin’s anti-Xa activity poses hematological risks requiring immediate attention.

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After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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