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 B

Explanation

Choice A reason: A soft diet with milk products may worsen diverticulosis, as dairy can cause bloating or intolerance. High fiber and fluids prevent constipation, reducing diverticular pressure. This is inappropriate, per dietary management and gastrointestinal health guidelines for diverticulosis in nursing education.

Choice B reason: A high fiber diet and increased fluid intake prevent constipation, reducing pressure in diverticula and preventing complications like diverticulitis. This promotes bowel regularity, critical for managing diverticulosis, per evidence-based dietary recommendations and gastrointestinal health protocols in patient education for nursing care.

Choice C reason: Small frequent meals and sitting up after meals aid digestion but do not address diverticulosis-specific needs. High fiber and fluids directly prevent constipation, reducing diverticular strain. This is less effective, per dietary management and patient teaching standards for diverticulosis in nursing.

Choice D reason: A bland diet avoiding spicy foods is unrelated to diverticulosis, which requires fiber to prevent constipation. Spicy foods do not directly affect diverticula. High fiber and fluids are critical, per gastrointestinal health and dietary management guidelines for diverticulosis in nursing education.

A. Administer the prescribed warfarin dose. B. Notify the healthcare provider immediately. C. Encourage increased intake of green leafy vegetables. D. Monitor for signs of bleeding every 8 hours.

Correct Answer is B

Explanation

Choice A reason: Administering warfarin with an INR of 4.8 is dangerous, as it exceeds the therapeutic range (2.0–3.0), indicating excessive anticoagulation. This risks bleeding, as warfarin inhibits vitamin K-dependent clotting factors. Notifying the provider ensures dose adjustment or reversal, preventing hemorrhage, making this action unsafe.

Choice B reason: An INR of 4.8 indicates over-anticoagulation in atrial fibrillation, increasing bleeding risk due to warfarin’s inhibition of clotting factors. Notifying the provider is critical for dose reduction or vitamin K administration, addressing the pathophysiological risk of hemorrhage, ensuring patient safety and preventing life-threatening complications.

Choice C reason: Encouraging green leafy vegetables, high in vitamin K, counteracts warfarin, lowering INR, but is inappropriate without provider guidance at INR 4.8, risking bleeding. Provider notification ensures controlled management, as unregulated dietary changes disrupt anticoagulation stability, making this action potentially harmful.

Choice D reason: Monitoring for bleeding is important but secondary to notifying the provider at INR 4.8, indicating critical over-anticoagulation. Immediate provider intervention adjusts warfarin or administers reversal agents, preventing hemorrhage. Monitoring delays urgent action needed to correct the clotting factor imbalance, making it less immediate.

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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

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

Correct Answer is B

Explanation

A client with a history of atrial fibrillation is prescribed warfarin. The nurse notes the client’s INR is 4.8. Which action should the nurse take? Reference Range: INR [2.0 to 3.0 for atrial fibrillation].

Correct Answer is B

Explanation

The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

The nurse is assessing a client who is admitted to the renal unit with suspected decreased renal perfusion. The nurse should plan to carefully monitor which parameter? Reference Range: Urine white blood cells (WBC) [0 to 4 WBC/low powered field (lpf)]

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