Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

Encourage fluid intake

Reduce fluid intake

Alert the healthcare provider of possible infection

No action is required

Answer and Explanation

The Correct Answer is A

Choice A rationale: Dark yellow urine may indicate concentrated urine, and encouraging fluid intake helps dilute the urine, promoting kidney function and preventing dehydration.
Choice B rationale: Reducing fluid intake is not appropriate based solely on the color of the urine. It is essential to assess overall hydration status.
Choice C rationale: Dark yellow urine alone does not necessarily indicate infection. Other symptoms and laboratory tests would be needed for a diagnosis.
Choice D rationale: Taking no action is not appropriate when the color of urine suggests dehydration. Assessing and addressing hydration status are important.

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Correct Answer is A

Explanation

Choice A rationale: A deep tissue injury involves intact skin with a purple or maroon localized area of discolored, non-blanchable, deep red or maroon, or a blood-filled blister due to damage of underlying soft tissue from pressure or shear. It is a stage that is more appropriate for the described wound involving the epidermis and dermis.
Choice B rationale: Stage III pressure ulcers involve full-thickness tissue loss, but they do not involve the epidermis and dermis.
Choice C rationale: Unstageable ulcers are covered with slough or eschar, making it difficult to determine the depth of tissue involvement. In this case, the wound's description indicates involvement of the epidermis and dermis.
Choice D rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, not just the epidermis and dermis.

Correct Answer is ["1.5"]

Explanation

Number of tablets = total dose/ tablet strength

= 30/20

= 1.5 tablets

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Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?

Correct Answer is A

Explanation

The patient is receiving 30 mg of citalopram daily for depression. Citalopram is available in 20 mg scored tablets. How many tablets should be administered? (Round to the nearest tenth.)

Correct Answer is ["1.5"]

Explanation

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