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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Taking the client to the toilet when they have the urge to defecate promotes a natural bowel pattern and is an essential aspect of bowel training.
Choice B rationale: Timing toilet visits based on a regular schedule may be part of a bowel training program, but waiting for the client to have the urge is more effective.
Choice C rationale: Timing toilet visits with meals may be part of a bowel training program, but taking the client when they have the urge is more effective.
Choice D rationale: Waiting for the client to experience abdominal cramping may lead to delayed toileting and is not recommended in a bowel training program.
Correct Answer is B
Explanation
Choice A rationale: Stage III pressure ulcers involve full-thickness tissue loss with visible fat but do not extend to the underlying muscle.
Choice B rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed muscle, bone, or other structures.
Choice C rationale: Stage II pressure ulcers involve partial-thickness skin loss but do not extend into the deeper layers.
Choice D rationale: Unstageable ulcers have a base covered by slough or eschar, making it difficult to assess the depth of tissue involvement. In this case, the wound's base is described as muscle, indicating a stage IV pressure ulcer.
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