An older adult male client tells the nurse of losing sleep because of having to get up several times at night to go to the bathroom. The client also reports having trouble starting his urinary stream, and he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?

Review the client's fluid intake prior to bedtime.

Obtain a fingerstick blood glucose level.

Collect a urine specimen for culture analysis.

Palpate the bladder above the symphysis pubis.

Answer and Explanation

The Correct Answer is D

Choice A reason: Reviewing the client's fluid intake prior to bedtime is important for managing nocturia, but it does not address the immediate concern of urinary retention and difficulty starting the urinary stream.

Choice B reason: Obtaining a fingerstick blood glucose level is relevant for diagnosing diabetes, which can cause increased urination. However, it does not directly address the current urinary symptoms.

Choice C reason: Collecting a urine specimen for culture analysis can help identify a urinary tract infection, but it does not provide immediate assessment information regarding the client's bladder status.

Choice D reason: Palpating the bladder above the symphysis pubis is the most immediate and relevant intervention. This assessment helps determine if the bladder is distended, indicating urinary retention, which is a common issue in older adult males and can cause the symptoms described.

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Correct Answer is A

Explanation

Choice A reason: Drawing air in through the nose and exhaling slowly through pursed lips is a technique known as pursed-lip breathing. This method helps improve gas exchange by keeping the airways open longer during exhalation, which aids in the removal of trapped air and reduces dyspneal.

Choice B reason: Increasing the breathing rate for a full 30 seconds is not recommended for clients with emphysema. Rapid breathing can lead to hyperventilation and increased work of breathing, which can exacerbate dyspneal.

Choice C reason: Raising hands above the head to expand the diaphragm might help in some situations, but it is not as effective as pursed-lip breathing for improving gas exchange and reducing dyspneal in clients with emphysema.

Choice D reason: Laying down on each side with knees bent and breathing from the abdomen is a relaxation technique that can help some clients, but it does not specifically address the need for improved gas exchange during episodes of dyspneal.

A. Crackles or coarse rales. B. Pleural friction rub. C. Low pitched, sonorous rhonchi. D. Diminished breath sounds.

Correct Answer is D

Explanation

Choice A reason: Crackles or coarse rales are typically associated with fluid in the airways, such as in cases of congestive heart failure or pneumonia, but they do not directly indicate a pleural effusion.

Choice B reason: A pleural friction rub is associated with pleuritis, where the inflamed pleurae rub against each other. It does not indicate decreased air flow in a specific lobe.

Choice C reason: Low pitched, sonorous rhonchi are related to secretions in the larger airways and are not specific to a pleural effusion or decreased air flow in one lobe.

Choice D reason: Diminished breath sounds in the left upper lobe are consistent with a pleural effusion, as the fluid can reduce air flow and sound transmission in that area. This finding directly correlates with the x-ray results showing decreased air flow in the entire left upper lobe.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Correct Answer is A

Explanation

The chest x-ray for a client who is admitted for pneumonia shows a pleural effusion with decreased air flow in the entire left upper lobe. After auscultating the left upper lobe, which breath sounds documented by the nurse verify the x-ray findings?

Correct Answer is D

Explanation

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