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A nurse is caring for a patient and notices that the patient's urine is dark amber, cloudy, and has an unpleasant odor. Which of the following conditions should the nurse associate these findings with? Which condition is associated with dark, cloudy, odorous urine?
- A. Urinary retention
- B. Urinary incontinence
- C. Urinary tract infection
- D. Urinary frequency
Correct Answer: C
Rationale: The correct answer is C: Urinary tract infection (UTI). Dark amber, cloudy, and odorous urine are common indicators of a UTI. The dark amber color may suggest the presence of blood or concentrated urine due to the infection. Cloudiness can result from the presence of bacteria, white blood cells, or other particles in the urine. The unpleasant odor is often caused by the presence of bacteria breaking down waste products in the urine. Urinary retention (A) usually presents with difficulty emptying the bladder, not changes in urine appearance. Urinary incontinence (B) refers to involuntary leakage of urine and is not typically associated with changes in urine characteristics. Urinary frequency (D) involves frequent urination but does not necessarily cause changes in urine appearance.
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A nurse is providing health promotion education to the parents of a toddler. Which information should the nurse include in the teaching?,Which information should be included in toddler health promotion education?
- A. Need for increased caloric intake.
- B. How to establish trust.
- C. Management of tantrums.
- D. How to encourage cooperative play.
- E. Dental care.
Correct Answer: A,C,D,E
Rationale: The correct answer includes information on caloric intake (A) to ensure the toddler's proper growth and development. Management of tantrums (C) is crucial for behavioral management. Encouraging cooperative play (D) fosters social skills. Dental care (E) is essential for oral health. Establishing trust (B) is important but not directly related to health promotion. No information is given for choices F and G.
A nurse is educating a patient with multiple sclerosis who has been prescribed baclofen. What guidance should the nurse include in the education? What guidance should the nurse include for baclofen?
- A. Consume the medication on an empty stomach.
- B. Anticipate initial development of diarrhea.
- C. Discontinue the medication immediately if a headache occurs.
- D. Avoid taking antihistamines with this medication.
Correct Answer: D
Rationale: Correct Answer: D - Avoid taking antihistamines with this medication.
Rationale:
1. Baclofen is a muscle relaxant used to treat muscle spasms in conditions like multiple sclerosis.
2. Antihistamines can potentiate sedative effects when taken with baclofen, leading to increased drowsiness and dizziness.
3. Combining baclofen with antihistamines can result in impaired motor function and cognitive abilities.
4. It is important to educate the patient to avoid taking antihistamines while on baclofen to prevent these potential adverse effects.
Summary of Incorrect Choices:
A. Consuming the medication on an empty stomach is not necessary for baclofen.
B. Diarrhea is not a common initial side effect of baclofen.
C. Headache is not a common adverse effect of baclofen that requires immediate discontinuation of the medication.
The nurse is preparing a medication for a patient and observes the date of expiration on the vial occurred 2 months ago. Which of the following actions should the nurse take? What should the nurse do with expired medication?
- A. Discard the medication.
- B. Return the medication to the pharmacy.
- C. Notify the provider.
- D. Give the medication.
Correct Answer: B
Rationale: The correct answer is B: Return the medication to the pharmacy. Expired medication may be less effective or even harmful. By returning it to the pharmacy, the nurse ensures proper disposal, preventing potential harm to patients. Discarding the medication (choice A) is correct, but returning it to the pharmacy is preferred for proper disposal. Notifying the provider (choice C) may be done after returning the medication. Giving the medication (choice D) should never be an option due to safety concerns.
A nurse is conducting discharge teaching for a patient who has seizures and a new prescription for phenytoin. Which statements by the patient indicate a need for further teaching? Which statement indicates a need for phenytoin teaching?
- A. I know that I cannot switch brands of this medication.
- B. I have made an appointment to see my dentist next week.
- C. I will notify my doctor before taking any other medications.
- D. I'll be glad when I can stop taking this medicine.
Correct Answer: D
Rationale: The correct answer is D: "I'll be glad when I can stop taking this medicine." This statement indicates a need for further teaching because phenytoin is typically a lifelong medication for managing seizures. Stopping it abruptly can lead to serious consequences such as increased risk of seizures. Therefore, the patient should be educated on the importance of adhering to the prescribed regimen.
Choice A is correct because it emphasizes the importance of not switching brands of phenytoin, as different formulations may have varying levels of the active ingredient. Choice B is important for overall health but not directly related to phenytoin teaching. Choice C is also crucial as phenytoin can interact with other medications, so notifying the doctor is necessary.
In summary, choice D is incorrect because discontinuing phenytoin without medical supervision can be harmful. Choices A, B, and C are correct as they address important aspects of managing phenytoin therapy.
Medication Administration Record
• 1700: Dextrose 5% in 0.45% sodium chloride (D5/0.45% NaCl) at 100 mL/hr
• 1700: Promethazine 25 mg IV bolus every 4 hours PRN for nausea/vomiting
• 1715: Morphine 4 mg IV bolus every 6 hours PRN for pain
• 2115: Acetaminophen 625 mg PO every 6 hours PRN if temperature > 38.6°C (101.5°F)
• Discontinue Morphine (Note: The morphine has not yet been administered as the order is due in the future.)
Nurses' Notes
The client was received from the Post Anesthesia Care Unit (PACU) with initial vital signs recorded. The client is drowsy but arouses to verbal stimuli and is oriented to person, place, and time. The client is able to move all extremities and follow simple commands.
The heart rhythm is normal sinus, bilateral radial and pedal pulses are +2, and capillary refill is less than 2 seconds. Respiratory rate is 18/min with clear lung sounds and oxygen saturation of 96% on 2 L via nasal cannula. Bowel sounds are hypoactive in all four quadrants. The indwelling urinary catheter is draining clear yellow urine. The dressing on the right knee is dry and intact, with no drainage noted.
At 1830, the client was repositioned for comfort with side rails up x2 and the call light within reach. The client remains somewhat lethargic but arouses easily and reports nausea and pain, rating the pain as 6 on a scale from 0 to 10. Metoclopramide 10 mg IV was administered at 1830 for nausea. The client is positioned comfortably with the side rails up and call light within reach.
Physical Examination
• Heart Rate: 88/min
• Respiratory Rate: 18/min
• Blood Pressure: 115/55 mm Hg
• Temperature: 36.4°C (97.5°F)
• Oxygen Saturation: 96% on 2 L via nasal cannula
• General Behavior: Drowsy but arouses easily, somewhat lethargic
• Pain Level: Rated as 6 on a scale from 0 to 10
• Bowel Sounds: Hypoactive in all four quadrants
• Urinary Output: Clear yellow urine from indwelling catheter
• Knee Dressing: Dry and intact with no drainage
A nurse is caring for a client who is 6 hours postoperative following a right knee arthroplasty. The client has been receiving medications and fluids as outlined below.Exhibits Complete the following sentence by selecting the most appropriate action from the choices below:
The nurse should first:---------------------,followed by--------------------------------------
- A. Administer additional morphine for pain management
- B. Reposition the client for comfort
- C. Assess the area where the restraint is to be placed on the client
- D. Pad the client’s wrists under the restrain
- E. Ensure the client’s call light is within reach
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: Postoperative pain; Parameter to Monitor: Pain level, Client comfort.
Rationale: After a knee arthroplasty, pain management is crucial for the client's comfort and recovery. Administering additional morphine (A) addresses postoperative pain. Repositioning the client (B) is important to prevent complications such as pressure ulcers. Assessing the area for the restraint (C) and padding the client's wrists (D) are not immediate priorities. Ensuring the call light is within reach (E) is important but not the first action to take.