Exhibits

Review H and P and nurse's note.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.

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Correct Answer is C

Explanation

A. Elevating the area and applying light pressure is not appropriate for a small raised area from an intradermal injection, which is usually a normal reaction and not an indication for elevation or pressure.
B. Applying a cold pack is unnecessary and may not be appropriate unless there is significant discomfort or an allergic reaction, which is not suggested by the description of a small, raised area.
C. Documenting the site where the medication was given is important for record-keeping and monitoring the reaction to the intradermal test. This helps in assessing normal reactions versus abnormal ones later.
D. Notifying the healthcare provider of an allergic response should be done if the reaction is severe or unexpected, but a small, round raised area is typically a normal response to an intradermal injection.

Correct Answer is ["0.8"]

Explanation

To calculate the volume of hydromorphone to administer, we can use the following formula:

Volume (mL) = Dose (mg) / Concentration (mg/mL)

In this case:

Dose = 3 mg
Concentration = 4 mg/mL

Plugging in the values:

Volume (mL) = 3 mg / 4 mg/mL = 0.75 mL

Therefore, the nurse should administer 0.8 mL of hydromorphone to the client.

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Naxlex Comprehensive Predictor Exams

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Correct Answer is C

Explanation

Correct Answer is ["0.8"]

Explanation

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