Nokea
The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?
- A. Fecal impaction
- B. Infrequent voiding
- C. Stress incontinence
- D. Burning with urination
Correct Answer: A
Rationale: Fecal impaction. The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.
You may also like to solve these questions
The nurse is collecting data from a 10-year-old client during a routine physical examination. Which of the following actions should the nurse take? Select all that apply.
- A. Use correct anatomical terminology while reinforcing teaching about self-care.
- B. Conduct a head-to-toe examination in the same sequence as an adult examination.
- C. Explain the purpose of the examination equipment and any procedures to the client.
- D. Offer the client a gown and allow the client to keep the underwear on during the examination.
- E. Ask the accompanying parent to rate and describe any pain the client may be experiencing.
Correct Answer: A, C, D
Rationale: Using anatomical terminology (A) promotes understanding. Explaining equipment and procedures (C) reduces anxiety. Offering a gown and allowing underwear (D) respects privacy. Adult examination sequences (B) may not suit pediatric needs, and parents rating pain (E) may not accurately reflect the child's experience.
The nurse is reinforcing medication instructions for the parents of a child prescribed amoxicillin/clavulanate (liquid) twice a day for acute sinusitis. Which instructions are most important for the parents to remember? Select all that apply.
- A. Administer the medication with food if nausea or diarrhea develops
- B. Complete the medication course even if the child is better
- C. Rash is a normal, expected side effect
- D. Shake the medicine well before use
- E. Use a household spoon to measure the dose
Correct Answer: A, B, D
Rationale: Taking with food (A) reduces GI upset, completing the course (B) prevents resistance, and shaking well (D) ensures proper dosing. Rash (C) is not normal and requires evaluation, and household spoons (E) are inaccurate.
During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give?
- A. Encourage the night nurse to provide the UAP with additional training
- B. Indicate that it is the night nurse's job to deal with staff problems
- C. Remind the night nurse that the UAP is doing the best job the UAP can
- D. Suggest that the night nurse discuss concerns with the nurse manager
Correct Answer: D
Rationale: Suggesting discussion with the nurse manager (D) addresses the issue professionally. Encouraging training (A), deflecting responsibility (B), or defending the UAP (C) are less appropriate.
The nurse is preparing to administer ear drops to a 5-year-old client. Which of the following actions should the nurse take?
- A. Pull the client's pinna upward and back.
- B. Help the client sit upright with the chin tilted down.
- C. Touch the dropper to the entrance of the ear canal.
- D. Remove the medication from the refrigerator just before use.
Correct Answer: A
Rationale: Pulling the pinna upward and back (A) straightens the ear canal in children over 3. Sitting with chin down (B), touching the canal (C), or cold drops (D) are incorrect.
The nurse is caring for a client with Guillain-Barré syndrome after a recent gastrointestinal illness. Monitoring for which symptom is a nursing care priority in this client?
- A. Diaphoresis with facial flushing
- B. Hypoactive or absent bowel sounds
- C. Inability to cough or lift the head
- D. Warm, tender, and swollen leg
Correct Answer: C
Rationale: Inability to cough or lift the head (C) indicates respiratory muscle weakness, a life-threatening complication in Guillain-Barré syndrome, making it the priority.