nurse is caring for a client with urinary retention. The client asks what causes them to have urinary retention. Which of the following statements should the nurse make regarding possible causes of urinary retention? (Select all that apply.)

"It may be caused by a stone lodged in your urethra."

"It may be caused by an underactive bladder from a neurological condition."

"It may be caused by a defective gene from one of your parents."

"It may be caused by a narrowing of the urethra."

Answer and Explanation

Correct Answer : A,B,D,E

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Correct Answer is D

No explanation

A. Discard residual gastric contents B. Test the PH of gastric aspirate. C. Auscultate sounds D. Warm the formula to body temperature E. Check the tube's placement and patency.

Correct Answer is ["B","E"]

Explanation

Correct Actions:

B. Test the pH of gastric aspirate.

Explanation: Testing the pH of gastric aspirate helps confirm that the NG tube is correctly positioned in the stomach. A pH of 4 or less generally indicates gastric placement. This step is crucial to avoid complications like aspiration and ensure proper feeding.

E. Check the tube's placement and patency.

Explanation: Ensuring that the tube is correctly positioned and patent (not blocked) is essential before administering feedings. This involves aspirating some of the gastric contents to confirm placement and flushing the tube with water to verify it is clear and functioning properly.

Incorrect Actions:

A. Discard residual gastric contents.

Explanation: While it is important to measure gastric residuals to assess the stomach's ability to handle the feeding, residuals are not discarded. Instead, they are measured and then returned to the stomach unless otherwise specified by the healthcare provider.

C. Auscultate sounds.

Explanation: Auscultation of bowel sounds is not typically required immediately before administering enteral feedings. However, assessing bowel sounds periodically can be part of overall monitoring to ensure proper gastrointestinal function.

D. Warm the formula to body temperature.

Explanation: Enteral feeding formulas are generally administered at room temperature, although some facilities may have specific protocols for warming. Most guidelines do not require warming formula to body temperature.

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nurse is caring for a client with urinary retention. The client asks what causes them to have urinary retention. Which of the following statements should the nurse make regarding possible causes of urinary retention? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a new diagnosis of acute kidney injury. The client states, "This is going to mess my life up." Which of the following is the best response by the nurse to assist the client to begin to understand the impact of this disease?

Correct Answer is D

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG Tube Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply)

Correct Answer is ["B","E"]

Explanation

A nurse is caring for a client newly diagnosed with benign prostatic hypertrophy (BPH). Which topics are important to include in the education about this disease? (Select all that apply.)

Among which is not a clinical finding of an overhydrated patient

The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?

An LPN is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration. Select all that apply

An LPN is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration. Select all that apply.

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