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The nurse is developing a teaching handout for female clients who return to the clinic for recurring urinary tract infections (UTI). Which client has the greatest risk for developing a UTI?
- A. An adolescent who drinks a minimum of four diet drinks daily.
- B. A client who is too busy at work to void when the urge occurs.
- C. A multipara who had pyelonephritis during her last pregnancy.
- D. An older adult who is usually incontinent of urine during the night
Correct Answer: C
Rationale: A history of pyelonephritis increases UTI risk due to prior severe urinary infection, unlike dietary habits or incontinence.
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A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?
- A. Fatigue related to disease exacerbation.
- B. Pain related to joint inflammation
- C. Impaired physical mobility related to joint pain.
- D. Self-care deficit related to disease progression.
Correct Answer: B
Rationale: Pain is the primary symptom of RA exacerbation, impacting quality of life and requiring immediate management.
An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?
- A. Encourage deep breathing and coughing exercises.
- B. Teach a family member to administer eye drops.
- C. Provide an eye shield to be worn while sleeping
- D. Obtain vital signs every 2 hours during hospitalization.
Correct Answer: C
Rationale: An eye shield is crucial to protect the operated eye from accidental injury during sleep, preventing rubbing and potential complications. Deep breathing and coughing can increase intraocular pressure, teaching medication administration is not an immediate priority, and frequent vital sign monitoring is excessive for cataract surgery.
Nurses' Notes
0900
The 54-year-old female client returned to room from postanesthesia care unit (PACU). Situation- background-assessment-recommendation (SBAR) communication reveals client has had no urine output during the anesthesia recovery period. Last void was 8 hours ago. Client positioned in bed. Warm blanket applied for comfort. IV fluids infusing.
1045
Client requesting pain medication and says has the urge to void. Wishes to use bedpan. Voided 75 mL.
1130
Client informs she continues to have the urge to void and feels, "Wet." Placed on bedpan. Voided 50 mL. Bladder palpated and feels full. Bladder scanner applied and revealed 600 mL residual urine.
The nurse is planning care for the client. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Actions to Take
Choices
A. Request prescription for external catheter device
B. Request prescription for straight catheter
C. Insert indwelling urinary catheter
D. Assist client to bathroom for voiding
E. Increase the IV fluid rate
- B. Potential Condition
Choices
A. Urinary Retention
B. Urinary tract obstruction
C. Overflow Urinary Incontinence
D. IV fluid intake
E. Frequency of voiding
- C. Parameters to monitor
Choices
A. Amount of urine output
B. Residual urine
C. Pain medication effects
D. IV fluid intake
E. Frequency of voiding
Correct Answer: A
Rationale: Urinary retention, indicated by high residual urine, requires straight and indwelling catheters, with monitoring of urine output and residual urine.
The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?
- A. Take the diuretic every day, regardless of weight loss or muscle weakness.
- B. Weigh yourself daily at the same time and report excessive weight loss.
- C. Limit fluid intake while taking the diuretic to reduce fluid retention.
- D. Stop taking the medication when the edema in the lower extremities subsides.
Correct Answer: B
Rationale: Daily weight monitoring helps evaluate diuretic effectiveness and detect complications. Continuous diuretic use despite weakness, limiting fluids, or stopping medication without consultation can lead to adverse outcomes.
Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?
- A. Watch for shortness of breath which may indicate a fat embolus.
- B. Begin range of motion exercises within the first 24 hours.
- C. Apply ice intermittently for the first 24 hours.
- D. After edema subsides, apply heat continuously.
Correct Answer: C
Rationale: Intermittent ice reduces swelling and pain in acute soft tissue injuries, prioritizing over other instructions.