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The nurse inserts an indwelling Foley catheter into the bladder of a postoperative client who has not voided for 8 hours and has a distended bladder. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client?
- A. Check the specific gravity of the urine.
- B. Clamp the tubing for 30 minutes and then release.
- C. Provide suprapubic pressure to maintain a steady flow of urine.
- D. Raise the collection bag high enough to slow the rate of drainage.
Correct Answer: B
Rationale: Rapid emptying of a large volume of urine may cause engorgement of pelvic blood vessels and hypovolemic shock, prolapse of the bladder, or bladder spasms. Clamping the tubing for 30 minutes allows for equilibration to prevent complications. Option 1 is an assessment and would not affect the flow of urine or prevent possible hypovolemic shock. Option 3 would increase the flow of urine, which could lead to hypovolemic shock. Option 4 could cause backflow of urine. Infection is likely to develop if urine is allowed to flow back into the bladder.
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A client with a known history of panic disorder comes to the emergency department and states to the nurse, 'Please help me. I think I'm having a heart attack.' What is the priority nursing action?
- A. Assess the client's vital signs.
- B. Encourage the client to use relaxation techniques.
- C. Identify the manifestations related to the panic disorder.
- D. Determine what the client's activity involved when the pain started.
Correct Answer: A
Rationale: Clients with a panic disorder can experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder for these signs and symptoms. Although options 2, 3, and 4 may be appropriate at some point in the care of the client, they are not the priority.
A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site?
- A. Dry sterile dressings
- B. Hydrocolloid dressings
- C. Wet, sterile saline dressings
- D. One-half-strength povidone-iodine dressings
Correct Answer: C
Rationale: A fasciotomy is an incision made extending through the subcutaneous tissue and fascia. The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require povidone-iodine. Additionally, povidone-iodine can be irritating to normal tissues.
A client who has sustained a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing?
- A. Peanut butter and jelly sandwich, apple, tea
- B. Chicken breast, broccoli, strawberries, milk
- C. Veal chop, boiled potatoes, Jell-O, orange juice
- D. Pasta with tomato sauce, garlic bread, ginger ale
Correct Answer: B
Rationale: The meal with the best potential to promote wound healing includes nutrient-rich food choices, including protein, such as chicken and milk, and vitamin C, such as broccoli and strawberries. The remaining options include one or more items with a low nutritional value, especially the tea, jelly, Jell-O, and ginger ale.
The nurse is assigned to care for a client experiencing hypertonic labor contractions. The nurse plans to conserve the client's energy and promote rest by performing which intervention?
- A. Keeping the TV or radio on to provide distraction
- B. Assisting the client with breathing and relaxation techniques
- C. Keeping the room brightly lit so the client can watch her monitor
- D. Avoiding uncomfortable procedures such as intravenous infusions or epidural anesthesia
Correct Answer: B
Rationale: Breathing and relaxation techniques aid the client in coping with the discomfort of labor and conserving energy. Noise from a TV or radio and light stimulation does not promote rest. A quiet, dim environment would be more advantageous. Intravenous or epidural pain relief can be useful. Intravenous hydration can increase perfusion and oxygenation of maternal and fetal tissues and provide glucose for energy needs.
When planning care for a client diagnosed with Cushing's syndrome, the nurse should include which intervention to prevent a common complication of this disorder?
- A. Monitoring glucose levels
- B. Encouraging rigorous exercise
- C. Monitoring epinephrine levels
- D. Encouraging visits from friends
Correct Answer: A
Rationale: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol by the adrenal cortex or the administration of glucocorticoids in large doses for several weeks or longer. In the client with Cushing's syndrome, increased levels of glucocorticoids can result in hyperglycemia and signs and symptoms of diabetes mellitus. Clients experience activity intolerance related to muscle weakness and fatigue; therefore, option 2 is incorrect. Epinephrine levels are not affected. Visitors should be limited because of the client's impaired immune response.