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","B","D"]

Explanation

Choice A rationale
Weighing the client daily, in the morning, is an important intervention for a client with heart failure (HF) being treated with diuretics for fluid volume excess. Daily weights can help monitor the client’s fluid status and the effectiveness of the diuretic therapy.
Choice B rationale
Teaching the client how to restrict dietary sodium is an important intervention for a client with HF being treated with diuretics for fluid volume excess. A low-sodium diet can help prevent fluid retention and exacerbation of HF3.
Choice C rationale
Monitoring coagulation laboratory values is not typically necessary for a client with HF being treated with diuretics for fluid volume excess, unless the client is also receiving anticoagulant therapy.
Choice D rationale
Observing for evidence of hypokalemia is an important intervention for a client with HF being treated with diuretics for fluid volume excess. Diuretics can cause loss of potassium, which can lead to hypokalemia.

Choice E rationale
Encouraging an oral fluid intake of 3,000 mL/day is not typically recommended for a client with HF being treated with diuretics for fluid volume excess. Excessive fluid intake can exacerbate HF3.

A. Maintain nasal packing. B. Monitor intake and output. C. Provide frequent oral care. D. Keep the head of the bed elevated to 30 degrees.

Correct Answer is D

Explanation

Choice A rationale
Maintaining nasal packing is important after a hypophysectomy, especially if the surgery was performed through the nose (transnasal). However, it is not the most important intervention for a patient with Cushing’s disease in the post-anesthesia care unit (PACU)4.
Choice B rationale
Monitoring intake and output is a standard nursing intervention in the PACU. It helps assess the patient’s fluid balance and kidney function. However, it is not the most important intervention for a patient with Cushing’s disease following a hypophysectomy.
Choice C rationale
Providing frequent oral care is important for patient comfort and prevention of infections, but it is not the most important intervention for a patient with Cushing’s disease in the PACU following a hypophysectomy.

Choice D rationale
Keeping the head of the bed elevated to 30 degrees is the most important intervention for a patient with Cushing’s disease in the PACU following a hypophysectomy. This position helps reduce swelling, decreases the risk of aspiration, and promotes effective breathing and drainage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

The nurse is monitoring a patient with Cushing’s disease in the post-anesthesia care unit (PACU) following a hypophysectomy. Which intervention is most important for the nurse to include in the patient’s plan of care?

Correct Answer is D

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?