In assessing a client with an indwelling urinary catheter following the provision of care by an unlicensed assistive personnel (UAP), the practical nurse (PN) observes that the catheter drainage bag, which is half- full, is attached to the side rail and the tubing is looped on the bed.

Which action should the PN implement?

Apply gloves and empty the drainage bag

Remove the looped tubing from the bed

Measure the urinary output in the bag

Attach the drainage bag to the bed frame

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Attach the drainage bag to the bed frame.

Choice A rationale:

Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full.

Choice B rationale:

Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag.

Choice C rationale:

Measuring the urinary output in the bag is a routine task but does not correct the improper placement of the drainage bag.

Choice D rationale:

Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.

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Naxlex Comprehensive Predictor Exams

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

Explanation

Choice B rationale:

Stroke is a condition that occurs when the blood supply to a part of the brain is interrupted, causing brain tissue damage. Facial drooping and garbled speech are common signs of stroke, especially if they occur suddenly and on one side of the face.Stroke is a medical emergency that requires immediate treatment to prevent further brain damage and complications

Choice C rationale:

An allergic reaction could cause various symptoms, but it typically does not result in facial drooping or garbled speech. Common signs of an allergic reaction include hives, itching, redness, and swelling of the skin, as well as difficulty breathing in severe cases (anaphylaxis). There is no mention of these symptoms in the client’s presentation.

Choice D rationale:

Malignant hypertension is a possibility given the client’s extremely high blood pressure reading. This condition refers to severe hypertension that can quickly lead to organ damage. However, while it can cause neurological symptoms if it leads to a hypertensive crisis, the specific symptoms of facial drooping and garbled speech are more indicative of a stroke. In conclusion, based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of a stroke as evidenced by neurological defects (facial drooping and garbled speech). The client’s high blood pressure and reported alcohol consumption are both risk factors for stroke. Immediate medical intervention is crucial to minimize brain damage and potential complications.

A. Ibuprofen 400 mg every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C). B. Enalapril 10 mg every morning. C. Supplemental oxygen 10 L/min via nasal cannula. D. Continuous pulse oximetry. E. Send blood for a complete blood count, electrolytes, blood cultures, and procalcitonin. F. Admit to the medical floor. G. Vital signs every 4 hours.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale:

Ibuprofen 400 mg every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C). This order is questionable because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can potentially increase blood pressure, which could be harmful to a patient with hypertension. Furthermore, NSAIDs can mask the symptoms of infection, which could delay the diagnosis and treatment of serious infections.

Choice B rationale:

Enalapril 10 mg every morning. This order is questionable because enalapril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. However, ACE inhibitors can cause a dry cough, which could exacerbate the patient’s existing cough due to pneumonia. Additionally, ACE inhibitors can potentially cause hyperkalemia (high potassium levels), so it’s important to monitor the patient’s electrolyte levels.

Choice C rationale:

Supplemental oxygen 10 L/min via nasal cannula. This order is questionable because a high flow rate of oxygen can potentially cause oxygen toxicity or hyperoxia, which can lead to cellular damage. The typical flow rate for a nasal cannula is between 1-6 L/min. A flow rate of 10 L/min may be too high for this patient, especially without a specified target SpO2 range.

Choice D rationale:

Continuous pulse oximetry. This order is appropriate because it allows for continuous monitoring of the patient’s oxygen saturation levels, which is crucial in a patient with pneumonia and shortness of breath.

Choice E rationale:

Send blood for a complete blood count, electrolytes, blood cultures, and procalcitonin. This order is appropriate because these tests can help monitor the patient’s overall health status and response to treatment.

Choice F rationale:

Admit to the medical floor. This order is appropriate because the patient requires hospitalization for treatment and monitoring due to his pneumonia.

Choice G rationale:

Vital signs every 4 hours. This order is appropriate because it allows for regular monitoring of the patient’s vital signs, which can help detect any changes in his condition.

Choice H rationale:

Chest x-ray now. This order is appropriate because a chest x-ray can help confirm the diagnosis of pneumonia and assess its severity.

Choice I rationale:

Sputum culture and sensitivity. This order is appropriate because it can help identify the specific organism causing the pneumonia and determine its antibiotic sensitivity, which can guide antibiotic therapy.

Choice J rationale:

Levofloxacin 500 mg intravenously every 24 hours. This order is appropriate because levofloxacin is a broad-spectrum antibiotic commonly used to treat pneumonia.

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Naxlex Comprehensive Predictor Exams

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

Explanation

Patient Data. Exhibits Which order would the nurse question? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

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The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago. Which complication is most important for the PN to anticipate?

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?