The nurse continues to care for the client.

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

Obtain a provider order for vaginal/anal culture.

Obtain a provider prescription for antibiotics.

Obtain a provider prescription for ibuprofen 600 mg every 6 hr for mild to moderate pain.

Obtain a provider prescription for phenazopyridine.

Obtain a provider order for a urine culture.

Answer and Explanation

Correct Answer : B,D,E

A. Obtain a provider order for vaginal/anal culture: A vaginal or anal culture is not indicated at this time because the client’s symptoms—dysuria, urinary frequency, and positive leukocyte esterase—are consistent with a urinary tract infection rather than a sexually transmitted infection or perianal infection.

B. Obtain a provider prescription for antibiotics: The client demonstrates signs of a urinary tract infection, including dysuria, positive leukocyte esterase, elevated WBC count, and cloudy urine. Prompt initiation of antibiotics is important in pregnancy to prevent complications such as pyelonephritis and preterm labor.

C. Obtain a provider prescription for ibuprofen 600 mg every 6 hr for mild to moderate pain: Ibuprofen is generally avoided during the third trimester because it can cause premature closure of the fetal ductus arteriosus and oligohydramnios. Alternative analgesics that are safe in pregnancy should be used instead.

D. Obtain a provider prescription for phenazopyridine: Phenazopyridine is a urinary analgesic that can help relieve dysuria and urinary discomfort while the client awaits antibiotic therapy. It does not treat the infection itself but improves client comfort.

E. Obtain a provider order for a urine culture: A urine culture is indicated to confirm the presence of infection and identify the causative organism. This ensures that antibiotic therapy can be tailored appropriately, which is especially important in pregnancy to reduce maternal and fetal complications.

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Correct Answer is C

Explanation

A. Offer the client saltine crackers between meals: Dry foods like saltine crackers can worsen the discomfort associated with xerostomia and may irritate oral mucosa. They are not recommended for managing dry mouth.

B. Instruct the client on the use of esophageal speech: Esophageal speech is a technique used after laryngectomy, not for managing xerostomia. It does not address the underlying issue of dry mouth caused by radiation therapy.

C. Provide humidification of the room air: Humidifying the room adds moisture to the environment, helping relieve dryness in the oral cavity and throat. This intervention is appropriate for managing xerostomia and improving comfort for clients post-radiation therapy.

D. Suggest rinsing his mouth with an alcohol-based mouthwash: Alcohol-based mouthwashes can further dry and irritate the oral mucosa, worsening xerostomia. Clients should be advised to use non-alcoholic, moisturizing rinses instead.

A. Evaluate the client's ability to help with repositioning B. Reposition the client without the use of assistive devices. C. Discuss the client's preferences for determining a repositioning schedule. D. Raise the side rails on both sides of the client's bed during repositioning.

Correct Answer is A

Explanation

A. Evaluate the client's ability to help with repositioning: Assessing the client’s strength, motor function, and level of cooperation is essential to determine how much assistance is needed and which repositioning techniques are safest. Stroke clients may have hemiplegia or weakness, and understanding their abilities prevents injury to both the client and the nurse.

B. Reposition the client without the use of assistive devices: Using assistive devices such as slide sheets, gait belts, or mechanical lifts is recommended for clients with limited mobility to reduce the risk of musculoskeletal injury. Repositioning without them increases the likelihood of strain or falls.

C. Discuss the client's preferences for determining a repositioning schedule: While client preferences can enhance comfort and adherence, safety and prevention of complications such as pressure injuries take priority. Scheduling should follow clinical guidelines rather than preference alone.

D. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a fall hazard or limit safe access for the nurse during repositioning. Typically, one side rail may be raised as needed, while the other is lowered to allow safe maneuvering.

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The nurse continues to care for the client. Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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