You note the following findings on your patient: (see chart below)

Vital Signs

Blood Pressure: 138/84

Heart Rate: 98 beats per minute

Respiratory Rate: 18 breaths per minute

Temperature: 99.6F

Pulse oximetry: 97% on room air

Pain: 7/10

Intake and output

Intake for past 12 hours: 2150mL

Output for past 12 hours: 150mL

Meals: 100% breakfast 75% lunch 90% dinner

Based on these findings, what intervention should you implement first?

Check the patient's urinalysis.

Notify the provider of the patient's pain 7/10

Perform a bladder scan

Assess the daily weight.

Answer and Explanation

The Correct Answer is C

A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.

B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.

C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.

D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Powered stand assist: Powered stand assist devices are used for clients who cannot bear weight independently, not for balance issues during ambulation.

B. Cane: A cane provides minimal support and is best for clients with mild weakness, not for those with frequent balance loss.

C. Gait belt: A gait belt provides stability and support while allowing the nurse to assist the client safely if they begin to lose balance.

D. Four-wheel walker: A four-wheel walker rolls easily, which may increase fall risk in a client with balance issues. A standard walker (without wheels) would be safer in some cases.

A. Green, soft stool after the patient received antibiotics B. Large, loose stool after the patient received a laxative C. Dry, hard stool from a patient receiving opiates. D. Black tarry stool from a patient receiving an anticoagulant

Correct Answer is D

Explanation

A. Green, soft stool after the patient received antibiotics: Green stool can be a side effect of antibiotics due to changes in gut flora but is not typically concerning.

B. Large, loose stool after the patient received a laxative: This is an expected outcome of laxative use and is not cause for concern.

C. Dry, hard stool from a patient receiving opiates: Opiates commonly cause constipation. While this requires management, it is not the most concerning finding.

D. Black tarry stool from a patient receiving an anticoagulant: Black tarry stool (melena) indicates gastrointestinal bleeding, which can be life-threatening, especially in a patient on anticoagulants. Immediate assessment is required.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?

Correct Answer is C

Explanation

The nurse is assessing the patient's output for the shift. What finding is most concerning?

Correct Answer is D

Explanation

A nurse is providing education to a female patient who has been diagnosed with recurrent urinary tract infections. What statement should the nurse include in the education?

The nurse is caring for a patient admitted with weakness and has a history of osteoporosis and obesity. What nursing intervention should the nurse implement while providing hygiene care?

While bathing a patient who is on bedrest, the nurse notes an area of blistering and hypopigmentation on the patient's right heel. Upon further assessment, the area is also tender and cooler than the surrounding area. What is the next best action by the nurse?

The nurse is providing education on how to prevent constipation to a group of older adults in a nursing facility. What should be included in the education?

A client is having difficulty having a bowel movement laying on the bedpan. What is the physiologic reason for this problem?

A client is on bed rest and an enema has been ordered. In what position should the nurse position the client?

The nurse has received a report for the following patients. Which patient should be seen first?