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 D

Explanation

A. How many popsicles are available.

This information might be helpful for logistical purposes or to assess how much the child has consumed, but it's not directly relevant to ensuring the appropriateness of the popsicles for a clear liquid diet.

B. If the popsicles are completely frozen.

While it's important that popsicles are properly frozen to avoid potential choking hazards, this does not address whether the popsicles meet the dietary requirement of clear liquids.

C. The color and flavor of gelatin used.

While this might be of interest, the key concern is whether the popsicles contain any non-clear components like fruit or pulp.

D. Whether they contain pulp or fruit.

For a child who needs clear liquids, it is important to ensure that the popsicles do not contain any solids like fruit or pulp. Clear liquids are meant to be easily digestible and not irritate the stomach further. Popsicles with pulp or fruit can be too heavy and might not be appropriate in this situation.

A. Assess strength of deep tendon reflexes. B. Determine apical pulse rate and rhythm. C. Compare muscle strength bilaterally. D. Observe color and amount of urine.

Correct Answer is B

Explanation

A. Assess strength of deep tendon reflexes:

Hyperkalemia can affect neuromuscular function, leading to alterations in deep tendon reflexes. However, determining the apical pulse rate and rhythm is more crucial as hyperkalemia can cause cardiac dysrhythmias and cardiac arrest.

B. Determine apical pulse rate and rhythm:

This is the most important intervention because hyperkalemia can lead to life-threatening cardiac dysrhythmias, including ventricular tachycardia and ventricular fibrillation. Monitoring the apical pulse rate and rhythm allows the nurse to detect any abnormalities promptly.

C. Compare muscle strength bilaterally:

Hyperkalemia can cause muscle weakness or paralysis due to its effects on neuromuscular function. While assessing muscle strength is important, monitoring cardiac function takes precedence because of the potential for life-threatening dysrhythmias.

D. Observe color and amount of urine:

Hyperkalemia can affect renal function, leading to changes in urine output and composition. While monitoring urine output and characteristics is important for assessing renal function, it is not the most critical intervention when managing acute hyperkalemia and its potential cardiac effects.

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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

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Correct Answer is D

Explanation

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is B

Explanation

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