Following surgery for a prolapsed bladder, a 74-year-old fem...

The following scenario applies to the next 6 items.
The nurse in the emergency department (ED) is caring for a 57-year-old male client.
Item 1 of 6
History and Physical
A 57-year-old male client with stage three small cell lung cancer. The client had suddenly become disoriented and did not recognize his family members and relatives. He reports severe lower extremity weakness and has had three episodes of diarrhea in the past four hours. The client is undergoing 6 cycles of chemotherapy with cisplatin and etoposide. He is currently taking a 14-day course of 15 mg of prednisone. He is on his third day of steroid treatment. He has a medical history of dyslipidemia and advanced chronic obstructive pulmonary disease.

Nurses' Notes
0759: Client is completely disoriented and required maximum assistance to the stretcher because of unsteady gait. Lung sounds clear bilaterally. Alopecia noted. Skin is warm and dry and normal for ethnicity. Peripheral pulses 2+. No skin tenting. Hyperactive bowel sounds in all quadrants. 20-gauge peripheral vascular access device placed in the left antecubital space. T 97.8° F (36.6° C) P 88 RR 21 BP 123/68 Pulse oximetry reading 91% on room air.

Laboratory Results
• Hemoglobin 14 g/dL [14-18 g/dL (140–180 g/L)]
• Hematocrit 42% (0.42) [42-52% (0.42-0.52)]
• White Blood Cell 11,000 mm3 [5-10 mm3]
• Platelet Count 140,000 mm3 [150-400 mm3 (150–400 × 109/L)]
• Glucose 139 mg/dL (7.72 mmol/L) [70–110 mg/dL (4-6 mmol/L)]
• Sodium 116 mEq/L [136–145 mEq/L (mmol/L)]
• Potassium 3.3 mEq/L [3.5–5.0 mEq/L (mmol/L)]
• Creatinine 0.7 mg/dL (61.88 mmol/L) [0.6–1.2 mg/dL (53–106 mmol/L)]
• Blood Urea Nitrogen 8 mg/dL (2.86 mmol/L) [10–20 mg/dL (3.6–7.1 mmol/L)]
• Serum Osmolality 277 mOsm/kg [285-295 mOsm/kg (285–295 mmol/kg)]

Which of the following assessment findings require immediate follow-up? Select all that apply.

A. mental status
B. reports of diarrhea
C. serum sodium
D. serum potassium
E. white blood cell count
F. serum glucose
G. alopecia

Correct Answer: A,C,D,F

Rationale: Mental status changes, severe hyponatremia (116 mEq/L), hypokalemia (3.3 mEq/L), and elevated glucose (139 mg/dL) require immediate attention due to potential neurological and cardiac risks.

The following scenario applies to the next 1 items
The student nurse is assisting the nurse in caring for a 31-year-old female in the outpatient clinic.
Item 1 of 1
Nurses' Note
1415: The client requested her annual physical be moved up because of urinary symptoms that started nine months ago. She states that she has managed so far with them, but she is starting a new traveling job and would like to get any necessary treatment. She states that every time she laughs or sneezes, she leaks a small amount of urine. She reports that this also occurs while performing intense physical exercise. The symptoms occur daily. She denies increased frequency, urgency, and burning upon urination. She denies having any vaginal discharge. She was treated for a urinary tract infection two months ago with antibiotics.

Diagnostic Results
1500:
Bladder scan - post-void residual
20 mL

Medical History
• Chronic low back pain following a motor vehicle crash
• Obstetric history - G = 2, T = 2 (vaginal deliveries), P = 0, A = 0, L = 2

The nurse reviews the concept of urinary incontinence, its causes, and symptoms with the student nurse. Click to specify if the causes or symptoms are consistent with the disease process of stress incontinence, overflow incontinence, or urge incontinence.

A. Urine loss with physical exertion, cough, sneeze, or exercise
B. Palpable bladder during assessment
C. Caused by neurologic disorders, such as multiple sclerosis or spinal cord damage
D. Caused by vaginal prolapse from vaginal birth or aging
E. Caused by bladder irritants, such as artificial sweeteners, caffeine, alcohol
F. Caused by constipation
G. Loss of large amounts of urine with each occurrence

Correct Answer: A: Stress incontinence, B: Overflow incontinence, C: Urge incontinence, D: Stress incontinence, E: Urge incontinence, F: Overflow incontinence, G: Overflow incontinence

Rationale: Stress incontinence involves urine loss with exertion. Overflow incontinence is associated with palpable bladder, constipation, and large urine loss. Urge incontinence is linked to neurologic disorders and bladder irritants.

The nurse is teaching a client who is scheduled for a 24-hour urine collection. The nurse should plan to

A. discard the second urine specimen and then start the collection.
B. discard the first and last urinary specimens.
C. discard the first urine specimen.
D. collect and retain all urinary specimens.

Correct Answer: C

Rationale: The first urine specimen is discarded to ensure the collection reflects a full 24-hour period starting from an empty bladder.

The nurse is caring for a client with a phosphorus level of 5.3 mg/dL (1.71 mmol/L) [normal range: 3.0-4.5 mg/dL (0.97-1.45 mmol/L)]. The nurse identifies which of the following as possible causes of this condition? Select all that apply.

A. tumor lysis syndrome
B. hypoparathyroidism
C. hypercalcemia
D. renal failure
E. anorexia

Correct Answer: A,B,D

Rationale: Tumor lysis syndrome, hypoparathyroidism, and renal failure cause hyperphosphatemia by increasing phosphate release or reducing excretion.

The nurse cares for a client with a potassium of 5.7 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. The nurse understands that this potassium level may be caused by Select all that apply.

A. Cushing's disease.
B. nasogastric tube suctioning.
C. salt substitutes.
D. hyperinsulinism.
E. adrenal insufficiency.

Correct Answer: C,E

Rationale: Salt substitutes (potassium-based) and adrenal insufficiency (reduced aldosterone) cause hyperkalemia.

Urinary NCLEX RN Questions Related

Correct Answer: B