The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Place a warm blanket on the client.

Administer IV fluids per protocol.

Review the medication administration record.

Check the urinary catheter r an occlusion.

Answer and Explanation

The Correct Answer is B

A. Place a warm blanket on the client: Providing warmth may improve comfort temporarily but does not address the underlying cause of the client’s cool, moist hands, prolonged capillary refill, or low urine output, which suggest possible hypovolemia or shock.

B. Administer IV fluids per protocol: The client’s signs restlessness, cool clammy skin, prolonged capillary refill, and low urine output indicate hypoperfusion likely due to fluid deficit. Administering IV fluids promptly helps restore circulating volume and tissue perfusion.

C. Review the medication administration record: While medication review is important for overall safety, it does not address the immediate risk of hypovolemic shock or low urine output in this client.

D. Check the urinary catheter for an occlusion: Although checking for blockage is reasonable if a catheter is present, the client’s overall clinical presentation points to systemic hypovolemia rather than a localized urinary obstruction.

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Correct Answer is D

Explanation

A. Palpate flank area: Flank assessment may help detect kidney tenderness or infection but is not the primary focus for routine suprapubic catheter care unless complications are suspected.

B. Assess perineal area: The suprapubic catheter bypasses the perineal route, so routine perineal assessment is less critical for catheter management, though general hygiene remains important.

C. Measure abdominal girth: Abdominal girth measurement is useful for detecting ascites or abdominal distention but is not directly relevant to monitoring a suprapubic catheter.

D. Observe insertion site: Regular inspection of the catheter insertion site is essential to detect signs of infection, leakage, irritation, or improper placement. This assessment helps ensure catheter function and prevents complications, making it the priority during home visits.

Patient Data

Exhibits

For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.

A. Reduced pulse distal to injury B. Decreased range of motion C. Coolness of skin D. Pain with movement E. 1+ strength in left upper extremity

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

Reduced pulse distal to injury: A humeral fracture can damage surrounding vasculature, especially the brachial artery, leading to compromised circulation. This results in weak or absent distal pulses, which requires urgent evaluation for possible neurovascular compromise.

• Decreased range of motion: Both rotator cuff injury and humeral fracture commonly cause impaired shoulder mobility. A rotator cuff tear limits abduction and overhead activities, while a fracture mechanically restricts movement due to pain, swelling, or bone displacement.

• Coolness of skin: A humeral fracture can impair blood flow by compressing or injuring vessels, producing ischemic changes such as cool skin. This finding signals inadequate perfusion, which can progress to serious complications if untreated.

• Pain with movement: Both a rotator cuff tear and humeral fracture are associated with pain on movement. In a tear, the pain stems from tendon injury and inflammation, while in a fracture, bone disruption and soft tissue trauma intensify pain when the joint is moved.

• 1+ strength in left upper extremity: Weakness in the affected arm is more typical of rotator cuff injury, as tendon disruption limits muscular function and reduces lifting ability. This differs from fracture-related pain, where strength may be preserved but restricted by pain.

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The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is D

Explanation

Patient Data Exhibits For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

Patient Data Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.

Patient Data Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

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