An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Give the client 8 ounces (236.5 mL) of water to drink.

Evaluate the client for bladder distention.

Instruct the client to attempt to urinate again.

Send the sample for laboratory evaluation.

Answer and Explanation

The Correct Answer is B

A. Give the client 8 ounces (236.5 mL) of water to drink:
While encouraging hydration is important for overall urinary function, providing water to drink may not immediately address the client's current situation of difficulty providing a urine sample. It's essential to first determine if bladder distention is contributing to the client's symptoms.

B. Evaluate the client for bladder distention:
Given the client's symptoms of lower abdominal discomfort and difficulty providing a urine sample despite feeling the urge to urinate, bladder distention should be assessed. Bladder distention could indicate urinary retention, which may require intervention to relieve the discomfort and prevent complications such as urinary tract infection or bladder rupture.

C. Instruct the client to attempt to urinate again:
While encouraging the client to attempt to urinate again may be appropriate, it's essential to first assess for bladder distention to determine if there is an underlying issue contributing to the client's difficulty in providing a urine sample.

D. Send the sample for laboratory evaluation:
Sending the urine sample for laboratory evaluation is important for diagnostic purposes, but in this case, it's more important to address the immediate concern of the client's difficulty in providing an adequate sample. Evaluating for bladder distention would help guide further assessment and management.

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Correct Answer is B

Explanation

A) White blood cell count (WBC): While an elevated WBC count can indicate infection or inflammation, it is not directly related to melena. Melena, which is black, tarry stool, is usually an indication of gastrointestinal bleeding, specifically from the upper GI tract.

B) Hematocrit: Hematocrit is a measure of the proportion of red blood cells in the blood. Monitoring hematocrit is essential in the context of melena because gastrointestinal bleeding can lead to a decrease in red blood cells, causing anemia. Therefore, tracking hematocrit levels helps assess the severity of blood loss and the client's overall oxygen-carrying capacity.

C) Glucose: Blood glucose levels are not directly related to melena. Monitoring glucose is crucial for managing diabetes and other metabolic disorders but does not provide information about bleeding or anemia.

D) Blood urea nitrogen (BUN): While BUN levels can increase with gastrointestinal bleeding due to the breakdown of blood proteins in the gut, it is not the primary test to monitor for the effects of bleeding. Hematocrit is more directly indicative of blood loss.

A. Tenderness. B. Crepitus. C. Thrill. D. Non-tender.

Correct Answer is D

Explanation

Answer: D

Rationale:

A) Tenderness:

Tenderness upon palpation is not considered a normal finding. It may indicate inflammation, injury, or other underlying conditions affecting the thoracic region. Tenderness requires further investigation to determine the cause and appropriate treatment.

B) Crepitus:

Crepitus, which is a crackling or popping sensation felt under the skin, is not a normal finding. It can be associated with subcutaneous air or gas, often resulting from trauma or infection. Identifying crepitus prompts further evaluation to determine the underlying issue.

C) Thrill:

A thrill is a palpable vibration or sensation over the chest, typically felt over an area of turbulent blood flow, such as a heart murmur. It is not considered a normal finding in the thoracic region and usually indicates an abnormal cardiovascular condition that requires further assessment.

D) Non-tender:

A non-tender thoracic region is considered a normal finding. Absence of tenderness upon palpation indicates no immediate signs of inflammation or injury in the thoracic area, suggesting that the palpation findings are within the expected range of normal physical examination.

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An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is B

Explanation

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

Correct Answer is D

Explanation

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