Patient Data

Exhibits

Review H and P and nurse's notes.

Identify 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 []

Potential Conditions

Overflow urinary incontinence

This is the correct choice because overflow urinary incontinence is the involuntary loss of urine due to a distended bladder that cannot empty completely. The client has cerebral palsy, which can affect the bladder muscles and nerves, causing them to lose coordination and contractility. The client is also non-verbal and has severe intellectual disability, which can impair his ability to sense or communicate the need to void. The client's clothes and sheets are wet, indicating that he has leaked urine. The client voided approximately 75 mL of urine, which is a small amount for an adult male. These signs suggest that the client has overflow urinary incontinence.

Actions to Take

Provide skin care

This is a correct choice because the nurse should provide skin care to the client who has overflow urinary incontinence. The nurse should cleanse the perineal area with mild soap and water, pat dry, and apply a barrier cream or ointment to protect the skin from moisture and irritation. The nurse should also change the client's clothes and sheets as needed to keep him dry and comfortable.

Place an incontinence containment product under the client

This is a correct choice because the nurse should place an incontinence containment product under the client who has overflow urinary incontinence. An incontinence containment product is a device or material that absorbs or collects urine, such as a diaper, pad, or catheter. The nurse should choose an appropriate product based on the client's preferences, needs, and abilities. The nurse should also monitor the product for leakage, odor, or infection, and change it regularly.

Parameters to Monitor

Intake and output

This is a correct choice because the nurse should monitor the intake and output of the client who has overflow urinary incontinence. The nurse should measure and record the amount and type of fluids that the client consumes and excretes. The nurse should also note the color, clarity, odor, and specific gravity of the urine. The nurse should compare the intake and output with the normal ranges for the client's age, weight, and condition. The nurse should report any abnormal findings or changes to the health care provider.

Post-void residual

This is a correct choice because the nurse should monitor the post-void residual of the client who has overflow urinary incontinence. Post-void residual is the amount of urine left in the bladder after voiding. The nurse can measure it by using a bladder scanner or inserting a catheter after the client voids. A normal post-void residual is less than 50 mL for an adult male. A high post-void residual indicates that the bladder is not emptying completely, which can lead to overflow urinary incontinence. The nurse should report any high post-void residual to the health care provider.

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Correct Answer is A

Explanation

Choice A: Notify the healthcare provider is the correct action because it is the nurse's responsibility to report any medication errors or adverse reactions to the prescriber as soon as possible.

Choice B: Document the event on the chart is not the next action because it should be done after notifying the healthcare provider and completing an incident report.

Choice C: Complete an incident report is not the next action because it should be done after notifying the healthcare provider and before documenting the event on the chart.

Choice D: Inform the nurse on the next shift is not the next action because it should be done after documenting the event on the chart and during handoff.

A. Request a family member to remain with the client. B. Ask for the support of one of the client’s friends. C. Use drawings that are universal for all cultures. D. Obtain a staff member who is a bilingual interpreter.

Correct Answer is D

Explanation

Choice A: Request a family member to remain with the client is not the best intervention because it may compromise the confidentiality and accuracy of the assessment. The family member may not be able to translate correctly or may influence the client’s responses.
Choice B: Ask for the support of one of the client’s friends is not the best intervention because it may also violate the privacy and validity of the assessment. The friend may not be qualified or willing to translate or may have a conflict of interest with the client.
Choice C: Use drawings that are universal for all cultures is not the best intervention because it may not be sufficient or appropriate for the assessment. Drawings may not convey all the information needed or may be misinterpreted by the client.
Choice D: Obtain a staff member who is a bilingual interpreter is the best intervention because it facilitates the communication and understanding between the nurse and the client. The interpreter should be trained and certified in medical terminology and cultural sensitivity.

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Patient Data Exhibits Review H and P and nurse's notes. Identify 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After an intravenous antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Correct Answer is A

Explanation

The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

The nurse administers morphine to a client for chest pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

The nurse is teaching a client how to self-administer low-molecular-weight heparin subcutaneously. Which instruction should the nurse include?

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

A client's wife has just learned that her husband is terminally ill. She is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

Patient Data

Exhibits

Review H and P and nurse's notes.

Identify 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.