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A client admitted from a nursing home after several recent falls needs a urine sample for culture and sensitivity. What should the nurse complete first?
- A. Obtain urine sample for culture and sensitivity.
- B. Administer intravenous antibiotics.
- C. Encourage protein intake and additional fluids.
- D. Consult physical therapy for gait training.
Correct Answer: A
Rationale: In this scenario, the priority intervention is to obtain a urine sample for culture and sensitivity. Older adults with recent falls may have atypical symptoms of urinary tract infection (UTI), which can present as new-onset confusion or falling. It is crucial to rule out UTI before initiating antibiotics. While administering antibiotics, encouraging protein intake, fluids, and consulting physical therapy are important interventions, they should follow the urine sample collection to ensure accurate diagnosis and appropriate treatment.
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A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily?
- A. Placing the tube in warm water
- B. Hyperextending the head while inserting the tube
- C. Removing the tube if any resistance to insertion is met
- D. Asking the client to swallow as the tube is being advanced
Correct Answer: D
Rationale: The correct action for the nurse to take to insert a nasogastric tube safely and easily is asking the client to swallow as the tube is being advanced. This action helps facilitate the passage of the tube through the esophagus into the stomach. Placing the tube in warm water (Choice A) is not a recommended practice for nasogastric tube insertion. Hyperextending the head (Choice B) can cause discomfort and is not necessary for safe insertion. Removing the tube if resistance is met (Choice C) is incorrect as it may cause harm or discomfort to the client. Asking the client to swallow helps the tube pass more smoothly and comfortably.
A client recovering from surgery has a large abdominal wound. Which of the following foods, high in vitamin C, should the nurse encourage the client to eat to promote wound healing?
- A. Steak
- B. Veal
- C. Cheese
- D. Oranges
Correct Answer: D
Rationale: Oranges are a rich source of vitamin C, which is essential for wound healing due to its role in collagen synthesis. Citrus fruits like oranges, as well as other fruits and vegetables such as strawberries, kiwi, bell peppers, and broccoli, are high in vitamin C. Meats like steak and veal are not significant sources of vitamin C; they are primarily sources of protein. Cheese is not a good source of vitamin C but does provide calcium and protein.
A client with a family history of polycystic kidney disease (PKD is being assessed by a nurse. For which clinical manifestations should the nurse assess? (Select all that apply.)
- A. Nocturia
- B. Flank pain
- C. Increased abdominal girth
- D. B & C
Correct Answer: D
Rationale: Clients with PKD commonly present with flank pain and increased abdominal girth due to abdominal distention caused by cysts. Bloody urine is also a common symptom due to tissue damage from PKD. Nocturia and dysuria are not typical manifestations of PKD. Constipation is not directly associated with PKD. Therefore, the correct choices are flank pain and increased abdominal girth, making option D the correct answer.
A client has an elevated blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first?
- A. Assess the client's dietary habits.
- B. Inquire about the client's use of nonsteroidal anti-inflammatory drugs (NSAIDs).
- C. Hold the client's metformin (Glucophage).
- D. Contact the health care provider immediately.
Correct Answer: A
Rationale: An elevated blood urea nitrogen (BUN)/creatinine ratio can indicate various conditions such as dehydration, urinary obstruction, catabolism, or a high-protein diet. The initial action the nurse should take is to assess the client's dietary habits to determine if the elevated ratio is related to diet. Inquiring about the use of NSAIDs is important as they can impact kidney function, but dietary causes should be ruled out first. Holding metformin or contacting the health care provider without assessing the dietary habits would be premature actions as they may not address the underlying cause of the elevated BUN/creatinine ratio.
The patient is receiving a high dose of intravenous azithromycin to treat an infection and taking acetaminophen for pain. The nurse should expect to review which lab values when monitoring for this drug's side effects?
- A. Complete blood counts
- B. Electrolytes
- C. Liver enzymes
- D. Urinalysis
Correct Answer: C
Rationale: When a patient is receiving a high dose of intravenous azithromycin, which is a macrolide antibiotic, in combination with acetaminophen, a potentially hepatotoxic drug, the nurse should monitor liver enzymes. High doses of macrolides when taken with hepatotoxic drugs like acetaminophen can lead to hepatotoxicity. Reviewing liver enzymes helps in early detection of liver damage. Complete blood counts (Choice A) are not typically affected by azithromycin or acetaminophen. Electrolytes (Choice B) are not directly impacted by these medications. Urinalysis (Choice D) is not specifically indicated for monitoring the side effects of azithromycin and acetaminophen combination therapy.