When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

When the client voided following catheter removal.

Color of the urine during the catheter removal.

Time of the last dose of IV antibiotic administration.

Intake and output reports for the previous shift.

Answer and Explanation

The Correct Answer is A

A. When the client voided following catheter removal:

This information is crucial because it indicates the return of the client's ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.

B. Color of the urine during catheter removal:

While the color of the urine during catheter removal may provide some insight into the client's urinary condition, it is not as critical as knowing when the client voided after catheter removal to assess urinary function.

C. Time of the last dose of IV antibiotic administration:

While the timing of the last dose of IV antibiotic administration is important for managing the client's urinary tract infection, it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.

D. Intake and output reports for the previous shift:

Intake and output reports are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.

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Correct Answer is C

Explanation

In this situation, the best approach for the nurse to use when questioning the client about sexual activity is:

A. Ask questions in a vague, nonspecific format.

This approach may lead to confusion or misunderstanding on the part of the client and may not elicit the necessary information about sexual activity. It's important for the questions to be clear and specific to ensure accurate assessment and appropriate care.

B. Get the most difficult questions over with first.

Starting with the most difficult or sensitive questions may put the client on the defensive or make them feel uncomfortable. It's generally more effective to build rapport and trust with the client before broaching sensitive topics.

C. Begin with questions that are less sensitive in nature.

This approach allows the nurse to establish rapport and build trust with the client before addressing more sensitive topics such as sexual activity. Starting with less sensitive questions can help the client feel more comfortable and open up about their concerns.

D. Share personal values to put the client at ease.

Sharing personal values may not be appropriate or helpful in this context, as it could potentially influence the client's responses and compromise the objectivity of the assessment. The focus should be on creating a safe and supportive environment for the client to discuss their health concerns without feeling judged.

A. Initiate a fall risk protocol for the client. B. Teach the client to shorten the stride to prevent falls. C. Determine the client's activity tolerance. D. Record the client's ability to perform ADLS safely.

Correct Answer is C

Explanation

A. Initiate a fall risk protocol for the client:

Initiating a fall risk protocol may be premature based solely on observations of an upright posture and a smooth, steady gait. While falls are a significant concern in older adults, these observations suggest that the client currently exhibits good balance and mobility, which may not warrant immediate initiation of a fall risk protocol. Fall risk assessments typically involve a comprehensive evaluation of multiple factors beyond posture and gait, such as medical history, medications, cognitive status, and environmental factors.

B. Teach the client to shorten the stride to prevent falls:

Teaching the client to shorten their stride to prevent falls may not be necessary based on the observed smooth and steady gait. Shortening the stride is often recommended for individuals who exhibit signs of imbalance or instability during walking. However, in this scenario, the client demonstrates a smooth and steady gait, suggesting that their current gait pattern is effective and does not pose an immediate risk of falling.

C. Determine the client's activity tolerance:

Assessing the client's activity tolerance is an appropriate next step in the nursing process. While the observed upright posture and smooth, steady gait are positive indicators of mobility, understanding the client's overall activity tolerance provides valuable insight into their functional capacity and ability to perform activities of daily living safely. This assessment helps tailor care interventions to meet the client's individual needs and promotes optimal independence and quality of life.

D. Record the client's ability to perform ADLs safely:

Documenting the client's ability to perform activities of daily living (ADLs) safely is an essential component of nursing assessment and documentation. However, it may not be the most immediate action to take following the observation of an upright posture and smooth, steady gait. While documenting findings is important for maintaining accurate records and facilitating communication among healthcare team members, further assessment of the client's activity tolerance would provide additional context for documenting their functional status accurately.

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When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to question the client about sexual activity. Which approach is best for the nurse to use?

Correct Answer is C

Explanation

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Correct Answer is C

Explanation

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

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The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

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