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 D

Explanation

Choice A reason: Evaluating for evidence of incontinence is important for understanding the full scope of the seizure's impact on the client. However, it is not the first priority immediately after a seizure. Ensuring the client's airway and breathing status takes precedence.

Choice B reason: Observing for lacerations to the tongue is relevant as it can indicate the severity of the seizure and the potential for airway obstruction. However, the most critical intervention immediately after the seizure is to assess the client's breathing and ensure they are not experiencing prolonged apnoea.

Choice C reason: Documenting the details of the seizure activity is necessary for medical records and future treatment planning. While it is important, it is not the immediate priority. The nurse must first ensure the client's safety and physiological stability.

Choice D reason: Observing for prolonged periods of apnoea is the most urgent intervention. Apnoea, or a pause in breathing, can lead to hypoxia and other serious complications if not addressed immediately. Ensuring that the client is breathing properly is the top priority after a seizure.

A. Serum potassium 5.0 me/L (5.0 mmol/L), serum sodium 138 me/L (138 mmol/L). B. Serum potassium 4.5 me/L (4.5 mmol/L), serum sodium 140 me/L (140 mmol/L). C. Serum potassium 3.5 me/L (3.5 mmol/L), serum sodium 142 me/L (142 mmol/L). D. Serum potassium 3.0 me/L (3.0 mmol/L), serum sodium 149 me/L (149 mmol/L).

Correct Answer is D

Explanation

Choice A reason: Serum potassium of 5.0 me/L and serum sodium of 138 me/L are within normal ranges and do not reflect the expected electrolyte imbalances due to dehydration from vomiting and diarrhea.

Choice B reason: Serum potassium of 4.5 me/L and serum sodium of 140 me/L are also within normal ranges. This does not reflect the typical imbalance caused by dehydration.

Choice C reason: Serum potassium of 3.5 me/L and serum sodium of 142 me/L are normal values. They do not indicate the electrolyte disturbances expected with dehydration from vomiting and diarrhea.

Choice D reason: Serum potassium of 3.0 me/L indicates hypokalaemia (low potassium), and serum sodium of 149 me/L indicates hypernatremia (high sodium). These imbalances are expected in a client with a history of fever, vomiting, and diarrhea, as these conditions can lead to loss of potassium and concentration of sodium due to dehydration.

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Naxlex Comprehensive Predictor Exams

While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A client reports a 2-day history of fever, vomiting, and diarrhea. The healthcare provider prescribes serum electrolyte levels to be obtained. Which laboratory results should the nurse expect?

Correct Answer is D

Explanation

After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement?

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