An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?
Obtain a urine specimen for culture and sensitivity.
Instruct in effective techniques to cleanse the glans penis.
Palpate the client's suprapubic area for distention.
Advise the client to maintain a voiding diary for one week.
The Correct Answer is C
Choice A reason: While obtaining a urine specimen is important for diagnosing infection, it does not address the immediate discomfort and potential urinary retention the client may be experiencing.
Choice B reason: Cleansing the glans penis is part of good hygiene but does not address the client's symptoms of a full bladder and weak urine flow.
Choice C reason: Palpating for suprapubic distention can provide immediate information about bladder fullness and potential urinary retention, which may require prompt intervention.
Choice D reason: Maintaining a voiding diary is useful for tracking symptoms over time but does not provide an immediate assessment or intervention for the client's current symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Cooling the bottle is not necessary and shaking it is only required if the instructions specify to do so to mix the medication.
Choice B reason: Inserting the tip of the dropper into the ear canal is not recommended as it can introduce bacteria and cause injury.
Choice C reason: Pulling the pinna up and back in adults helps to straighten the ear canal, allowing for proper delivery of the medication.
Choice D reason: Administering the drops with the head held upright is not the correct method; the head should be tilted to allow the drops to flow down into the ear canal.
Correct Answer is ["400"]
Explanation
Step 1: Convert the volume of fluid to be infused from mL to L (since the rate is usually measured in mL/hr):
200 mL = 200 mL (No conversion needed as the volume is already in mL)
Step 2: Convert the time for infusion from minutes to hours (since the rate is usually measured in mL/hr):
30 minutes = 30 ÷ 60 = 0.5 hours
Step 3: Calculate the rate (volume ÷ time):
Rate = Volume ÷ Time
Rate = 200 mL ÷ 0.5 hours
Rate = 400 mL/hr
The nurse should program the infusion pump to deliver at a rate of 400 mL/hr.
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