You note the following findings on your patient: (see chart below)
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Vital Signs
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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
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Intake and output |
Intake for past 12 hours: 2150mL Output for past 12 hours: 150mL Meals: 100% breakfast 75% lunch 90% dinner
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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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The relationship occurs spontaneously: Therapeutic relationships are intentional and structured, unlike spontaneous social interactions.
B. It is based on the needs of the nurse: The relationship is centered on the needs of the client, not the nurse.
C. The nurse and client will have a social relationship: A therapeutic nurse-client relationship is professional, not social. It focuses on supporting the client’s well-being.
D. The nurse is accountable for the outcome: The nurse is responsible for maintaining professional boundaries and ensuring that the relationship supports the client’s health goals.
Correct Answer is D
Explanation
A. "This new room has negative pressure and does six to twelve air changes an hour and disposes the air outside to reduce the infection potential in other patients. I also have to wear this surgical mask."
While this provides technical information, the surgical mask part is incorrect; the nurse should wear an N95 respirator, not a surgical mask.
B. "It sounds like you have some questions about your new diagnosis. What are you most concerned about?"
While this is a therapeutic communication technique, it does not directly answer the patient's question about airborne precautions.
C. "Tuberculosis can seriously impair the lungs and requires a long course of antibiotics to treat it."
This statement provides disease information but does not explain why airborne isolation is necessary.
D. "Tuberculosis is a small particle that can spread through the air. This new room has a special filter that reduces the spread of the bacteria through the air."
This provides a concise and accurate explanation of airborne precautions in terms the patient can understand.
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