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 A

Explanation

A. Inject in abdominal area at least 2 in (5.1 cm) from the umbilicus:

This instruction is accurate and appropriate for the administration of low molecular weight heparin subcutaneously. Injecting into the abdominal area at least 2 inches (5.1 cm) away from the umbilicus is a commonly recommended site for subcutaneous injections due to the availability of subcutaneous tissue and the reduced risk of injury to underlying structures.

B. Rotate injections between the abdomen and gluteal areas:

While rotation of injection sites is important to prevent tissue damage and lipodystrophy, for subcutaneous injections of low molecular weight heparin, the abdomen is typically the preferred site due to better absorption and reduced risk of complications. Therefore, rotating between the abdomen and gluteal areas may not be necessary or recommended for this specific medication.

C. Expel the air in the prefilled syringe prior to injection:

Expelling air from the prefilled syringe is a standard practice to ensure accurate dosing and prevent air embolism, but it is not specific to the administration of low molecular weight heparin. This instruction should be included in general injection technique education but is not specific to the administration of this medication.

D. Massage the injection site to increase absorption:

Massaging the injection site after administration of low molecular weight heparin is not recommended, as it can increase the risk of bleeding or hematoma formation at the injection site. Massaging the site is generally contraindicated for anticoagulant injections to avoid disrupting the clotting process.

Correct Answer is ["1"]

Explanation

To determine how many tablespoons the client should take with each dose, we need to first calculate the dosage in tablespoons based on the concentration of the oral suspension.

Given:

Dextromethorphan oral suspension concentration: 30 mg per 15 mL

To find out how many milliliters the client should take per dose:

The prescribed dose is 30 mg.

So, if 15 mL contains 30 mg, then 1 mL contains:

30 mg / 15 mL = 2 mg/mL

To find out how many milliliters the client should take for the prescribed dose:

30 mg / 2 mg/mL = 15 mL

Now, we know that the prescribed dose is 15 mL. To convert this to tablespoons, we can use the fact that 1 tablespoon (tbsp) is equal to 15 milliliters.

So, the client should take:

15 mL / 15 mL/tbsp = 1 tablespoon

Therefore, the nurse should instruct the client to take 1 tablespoon with each dose.

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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 teaching the client to self administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse Include?

Correct Answer is A

Explanation

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

Correct Answer is ["1"]

Explanation

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