The nurse continues to care for the client.

Nurses' Notes Day 1, 0900:

Client reports lower back pain and pinkish vaginal discharge. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
FHR baseline 145, minimal variability.

Cervical exam indicates 2 cm, 50% effaced, 0 station. Membranes intact.
CBC and urinalysis collected and sent to lab. Day 1,0930:
Peripheral IV initiated. Provider prescriptions received and implemented. Day 1, 1000:
Client voided and reports pain and dicomfort upon urination. Client states, "I've noticed burning wife I urinate for the past 2 days."

Which of the following actions should the nurse take? Select all that apply.

Urine culture

Ibuprofen 600 mg every 6 hr for mild to moderate pain

Obtain provider prescription for phenazopyridine

Vaginal culture

Obtain provider prescription for antibiotics

Answer and Explanation

Correct Answer : A,C,E

A.   Urine culture: This will help identify the presence of any urinary tract infection (UTI) causing discomfort and burning during urination.
B.   Ibuprofen 600 mg every 6 hr for mild to moderate pain: While ibuprofen can help with pain relief, it does not address the potential underlying urinary tract infection, so it's important to address the infection first.
C.   Obtain provider prescription for phenazopyridine: Phenazopyridine is a urinary analgesic that can provide relief from the pain and discomfort associated with UTIs.
D.   Vaginal culture: The client's symptoms are related to discomfort and burning upon urination, suggesting a urinary tract issue rather than a vaginal issue. Therefore, a vaginal culture may not be relevant in this context.
E.   Obtain provider prescription for antibiotics: If a urinary tract infection is suspected based on the client's symptoms and urine culture results, antibiotics may be needed to treat the infection.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Opioid medications can cause constipation, and increasing fluid intake helps prevent dehydration and promotes bowel regularity. However, it does not directly prevent cosntipation.

B. Incorrect. While some laxatives or stool softeners might be recommended, mineral oil is generally not recommended due to its potential to interfere with the absorption of fat-soluble vitamins.

C. Incorrect. Increasing insoluble fiber intake, rather than decreasing it, can help prevent constipation.

D. Increasing exercise is key in preventing constipation caused by opiod analgesics

A. Loop the tubing so that it is lower than the collection bag. B. Keep the urinary bag at bladder level when ambulating. C. Obtain urinary samples by disconnecting the tubing connections. D. Secure the catheter to the client's thigh.

Correct Answer is B

Explanation

Choice A rationale:

Looping the tubing so that it is lower than the collection bag creates a dependent loop where urine can pool, increasing the risk of UTI. This practice should be avoided as it can lead to bacterial contamination and subsequent infections.

Choice B rationale:

Keeping the urinary bag at bladder level when ambulating helps maintain a continuous flow of urine into the collection bag without creating dependent loops. This practice minimizes the risk of bacterial contamination and reduces the chances of acquiring a UTI.

Choice C rationale:

Obtaining urinary samples by disconnecting the tubing connections is not recommended. This procedure can introduce bacteria into the urinary system, increasing the risk of UTI. Sterile techniques, such as using a catheter port for sampling, should be followed to minimize the risk of infection.

Choice D rationale:

Securing the catheter to the client's thigh is essential to prevent tension and pulling on the catheter, which can cause trauma to the urethra. However, securing the catheter alone does not minimize the risk of UTI. Proper hygiene, closed drainage system, and maintaining a continuous flow of urine into the collection bag are key factors in preventing UTIs in clients with indwelling urinary catheters.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has chronic pain about avoiding constipation from opioid medications. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter.Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?

Correct Answer is B

Explanation

A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?

A nurse inadvertently administered 160 mg of valsartan PO to a client who was scheduled to receive 80 mg. Which of the following actions is the priority for the nurse to take?

A nurse is caring for a postpartum client in an outpatient setting. Exhibits A nurse is caring for a postpartum client in an outpatient setting. Complete the following sentence by using the lists of options. The client is at highest risk for developing evidenced by the client's

A nurse is planning care for a client who is experiencing benzodiazepine toxicity.The nurse should plan to administer which of the following medications?

A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include?

A nurse in an outpatient clinic is caring for a client Vital Signs BP 124/68 mm Hg Heart rate 80/min Temperature 37° C (98.6° F) Respiratory rate 16/min Weight 67.1 kg (148 lb)

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?