Exhibits

The nurse has reviewed the laboratory results and flow sheet.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.

The nurse recognizes that the client has
dropdown
incontinence and
dropdown
which may be caused by benign prostate hyperplasia.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Bladder retention: The client reports increased urinary urgency and frequency, waking at night to void, and instances of incontinence. These symptoms are consistent with bladder retention, where the bladder does not empty completely, often seen in benign prostatic hyperplasia (BPH).

Overflow incontinence: This type of incontinence occurs when the bladder is full, and small amounts of urine leak out due to an inability to empty the bladder properly, commonly associated with BPH.

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Correct Answer is C

Explanation

A. Assessing papillary reactions to light is important in a neurological assessment but is not the priority in this situation.

B. Measuring and recording abdominal girth is not relevant to the client's current symptoms.

C. Auscultating over the main stem bronchus is the priority action as the client's symptoms suggest potential airway compromise, possibly from inhalation injury or swelling. Early identification and management of airway issues are critical in burn patients.

D. Determining the time of last oral intake is part of a comprehensive assessment but is not the immediate priority when airway compromise is suspected.

Correct Answer is ["21"]

Explanation

To calculate the flow rate in gtt/min, you can use the formula: (Volume in mL * Drop factor) / Time in minutes.

For 1 L of lactated Ringer's IV, which is 1000 mL, to be infused over 12 hours (720 minutes), with a drop factor of 15 gtt/mL, the calculation would be: (1000 mL * 15 gtt/mL) / 720 minutes = 15000 gtt / 720 minutes ≈ 20.83 gtt/min.

Therefore, the nurse should regulate the infusion to approximately 21 gtt/min.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["21"]

Explanation

Exhibits The nurse reviews the healthcare provider's orders. Select the 4 things the nurse should educate the client about taking his medication.

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

Patient Data Exhibits The nurse reviews the prescriptions and assessment data. Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.