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 []

Explanation

Hypoxia: The client's symptoms of confusion, blue lips (cyanosis), and a low oxygen saturation of 75% on room air indicate severe hypoxia, which requires immediate intervention to restore adequate oxygenation.
Replace the non-rebreather mask: This action ensures that the client receives the prescribed oxygen therapy at the correct flow rate, which is critical for increasing oxygen levels in the blood.
Increase the flow of oxygen to 12 L: Adjusting the oxygen flow rate to the prescribed level is necessary to effectively increase the client's oxygen saturation and relieve hypoxia.
Oxygen saturation: Monitoring oxygen saturation is essential to assess the effectiveness of the oxygen therapy and ensure that the client's oxygen levels are being maintained above 88%, as per the orders.
Level of consciousness: Monitoring the client’s level of consciousness helps evaluate the impact of hypoxia on the brain and determines whether the interventions are improving the client's neurological status.

A. Power flush with 60 mL to remove mucous obstructions. B. Slowly irrigate catheter with saline using an infusion pump. C. Clamp the catheter for 30 minutes prior to irrigating. D. Use a sterile syringe to irrigate with 20 mL normal saline.

Correct Answer is D

Explanation

A. Power flushing with 60 mL of solution can create excessive pressure in the bladder, increasing the risk of trauma or forcing bacteria into the urinary tract. Gentle irrigation is preferred to safely remove clots and sediment without causing injury.

B. Using an infusion pump to slowly irrigate the catheter may not allow proper control of pressure and volume, which can damage the bladder mucosa. Manual irrigation allows the nurse to assess resistance and stop if obstruction or discomfort occurs.

C. Clamping the catheter for 30 minutes before irrigation can increase bladder pressure and cause discomfort or potential reflux of urine into the kidneys. Routine pre-irrigation clamping is not recommended unless specifically ordered for retention management.

D. Using a sterile syringe with 20 mL of normal saline allows controlled, gentle irrigation to remove clots and sediment. Sterile technique reduces the risk of introducing pathogens, and the small volume minimizes bladder trauma while effectively clearing the catheter.

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Naxlex Comprehensive Predictor Exams

Exhibits 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.

Correct Answer is []

Explanation

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

Correct Answer is D

Explanation

The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?

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During the prodromal stage of an infection, which is the priority nursing intervention?

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To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?