The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours.
What additional action should the nurse instruct the UAP to perform each time the client is turned?

Offer the client oral fluids.

Feed the client a snack.

Assess the breath sounds.

Empty the urinary drainage bag.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Offering the client oral fluids is important for hydration, but it may not be appropriate for all patients, especially those with certain medical conditions or those who are NPO (nothing by mouth)7.
Choice B rationale

Feeding the client a snack can help maintain energy levels, but it may not be appropriate for all patients, especially those with dietary restrictions or those who are NPO7.
Choice C rationale
Assessing breath sounds is an important part of respiratory assessment, but it is not typically within the scope of practice for unlicensed assistive personnel (UAP). This task should be performed by a licensed nurse.
Choice D rationale
Emptying the urinary drainage bag is an appropriate task for a UAP to perform each time the client is turned. This helps ensure accurate measurement of urinary output and prevents infection by keeping the bag below the level of the bladder.

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Correct Answer is A

Explanation

Choice A rationale
A large, non-tender, hardened lymph node without overlying tissue inflammation could indicate malignancy. Lymph nodes may become enlarged or hard due to the presence of cancer cells.
Choice B rationale

While bacterial infections can cause lymph node enlargement, they typically also cause tenderness and overlying skin changes, such as redness or warmth.
Choice C rationale
Viral infections can cause generalized lymph node enlargement, but the nodes are usually tender and not hard.
Choice D rationale
Lymphangitis, or inflammation of the lymphatic channels, typically presents with red streaks on the skin, fever, and tenderness.

Correct Answer is ["1.8"]

Explanation

The client weighs 132 pounds. To convert pounds to kilograms, divide the weight in pounds by

2.2. So, the client’s weight in kilograms is: Step 1: 132 pounds ÷ 2.2 = 60 kg The prescription for dantrolene is 1.5 mg/kg. To find out how many milligrams the client should receive, multiply the client’s weight in kilograms by the dosage in mg/kg: Step 2: 60 kg × 1.5 mg/kg = 90 mg The vial is reconstituted to yield a concentration of 50 mg/mL. To find out how many mL the nurse should administer, divide the total dosage in milligrams by the concentration in mg/mL: Step 3: 90 mg ÷ 50 mg/mL = 1.8 mL So, the nurse should administer 1.8 mL of dantrolene.

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The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to perform each time the client is turned?

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Naxlex Comprehensive Predictor Exams

An adult patient visits the clinic expressing concern about a lump that appeared on their neck about a week ago. Upon examination, the nurse finds a large, non-tender, hardened left subclavian lymph node without any overlying tissue inflammation. What could these findings indicate?

Correct Answer is A

Explanation

Correct Answer is ["1.8"]

Explanation

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The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours.
What additional action should the nurse instruct the UAP to perform each time the client is turned?