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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Correct Answer is C

Explanation

The correct answer is: C. Bronchospasm.

Metoprolol is a selective beta-1 blocker, primarily affecting the heart, but it can still have some impact on beta-2 receptors in the lungs. In clients with respiratory conditions like asthma or COPD, beta-blockers can trigger bronchospasm, leading to breathing difficulties.

Here's why the other options are less likely to be adverse effects of metoprolol:

A. Tachycardia: Metoprolol actually lowers heart rate, so tachycardia is not a typical adverse effect. Instead, bradycardia (slow heart rate) is more common.
B. Hyperglycemia: Beta-blockers can sometimes mask symptoms of hypoglycemia, but they don’t directly cause high blood sugar.
D. Hyperkalemia: Metoprolol doesn’t significantly affect potassium levels, so hyperkalemia is not a common concern.

Since metoprolol is frequently used in hypertension management, nurses must monitor clients for bradycardia, hypotension, and signs of bronchospasm, especially in individuals with respiratory disorders.

A. A. "You must ambulate to avoid complications which could cause more discomfort than ambulating." B. B. "I know you feel angry about the pain of ambulation, but this is a necessary part of getting well." C. C. "Your healthcare provider has left specific instructions to ambulate on the first postoperative day." D. D. "I will be back in 30 minutes to help you get out of bed and walk around the room today."

Correct Answer is D

Explanation

An 18-year-old client with a mild mental disability is a client who has a lower than average intellectual functioning and some limitations in adaptive skills, such as communication, socialization, and self-care. A mild mental disability may aﬀect the client's ability to understand, cope, or cooperate with medical interventions, such as ambulation after surgery.

Ambulation is the act of walking or moving around. It is an important part of postoperative care, as it helps to prevent complications such as deep vein thrombosis, pulmonary embolism, pneumonia, atelectasis, constipation, and pressure ulcers. Ambulation also promotes circulation, wound healing, and muscle strength.

When the practical nurse (PN) atempts to assist the client to ambulate on the first postoperative day after an appendectomy, the client becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" This may indicate that the client is experiencing pain, fear, anxiety, or frustration due to the surgery and the recovery process .

The best response for the PN to make is to acknowledge the client's feelings, provide reassurance and support, and set a clear and realistic goal for ambulation. This will help to establish rapport, reduce resistance, and motivate the client to participate in the care plan.

Therefore, option D is the correct answer, as it shows empathy and respect for the client's feelings, while also informing the client of the expectation and time frame for ambulation. Option D also allows the client some time to prepare mentally and physically for the activity.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypertension and is prescribed metoprolol, a beta blocker. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is C

Explanation

When the practical nurse (PN) atempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?

Correct Answer is D

Explanation

Patient Data Exhibits The nurse notes that the client’s oxygen saturation is 88% on room air. What is the priority action by the nurse?

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide?

A nurse is teaching a client who has a urinary tract infection (UTI) about trimethoprim/sulfamethoxazole. The client asks why he needs to take two antibiotics together. What should the nurse say?

Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

An older client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) bathe her is becoming increasingly agitated and stating the UAP wants to hurt her and tie her up. Which approach should the nurse use with the client?​​​​​​

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?