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.

Answer and Explanation

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.

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Correct Answer is ["0.3"]

Explanation

Step 1: Convert the client's weight from lbs to kg using the conversion factor you provided (1 kg = 2.2 lbs).

So, 110 lbs × (1 kg ÷ 2.2 lbs) = 50 kg

Step 2: Calculate the daily dosage of dalteparin in units using the prescription (150 units/kg).

So, 50 kg × 150 units/kg = 7500 units

Step 3: Determine how many mL of the medication this dosage corresponds to using the information on the syringe (7500 units/0.3 mL).

So, 7500 units × (0.3 mL ÷ 7500 units) = 0.3 mL

The nurse should administer 0.3 mL of dalteparin to the client.

A. Thick, dry, and dark area on bilateral heels. B. Broken skin without evidence of undermining. C. Defined area of persistent redness over bone. D. Superficial sacral ulcer with defined margins.

Correct Answer is C

Explanation

Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.

Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.

Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.

Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who weighs 110 lbs has received a prescription for dalteparin, 150 units/kg to be administered subcutaneously daily for 4 months. The medication is available in a 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Please enter the numerical value only.)

Correct Answer is ["0.3"]

Explanation

A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Correct Answer is C

Explanation

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