Nokea
What action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder?
- A. Decrease the patient's evening fluid intake.
- B. Teach the patient how to use the Cred method.
- C. Suggest the use of adult incontinence briefs for nighttime only.
- D. Assist the patient to the commode every 2 hours during the day.
Correct Answer: B
Rationale: For a 40-year-old patient with multiple sclerosis experiencing urinary retention due to a flaccid bladder, teaching the Cred method is the appropriate action. The Cred method involves applying manual pressure over the bladder to aid in bladder emptying. Decreasing fluid intake is not the correct approach as it will not address the underlying issue of bladder emptying and may lead to dehydration and urinary tract infections. Using adult incontinence briefs only addresses the symptom of incontinence without addressing the bladder emptying problem. Assisting the patient to the commode every 2 hours does not actively address the issue of improving bladder emptying as effectively as teaching the Cred method.
You may also like to solve these questions
A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment finding should the nurse immediately report to the health care provider?
- A. Patient is claustrophobic.
- B. Patient is allergic to shellfish.
- C. Patient recently used a bronchodilator inhaler.
- D. Patient is not able to remove a wedding band.
Correct Answer: B
Rationale: The correct answer is that the patient is allergic to shellfish. This is crucial because the contrast media used in CT scans is iodine-based, and individuals with iodine allergies, such as those allergic to shellfish, are at risk of adverse reactions. It is important to identify and address this allergy to prevent potential complications. The other options do not directly impact the safety or effectiveness of the CT scan with contrast media. Claustrophobia can be managed with patient support, the recent use of a bronchodilator inhaler does not typically affect the CT procedure, and not being able to remove a wedding band is not a critical concern for the scan itself.
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
- A. Performing a chest x-ray via stretcher
- B. Obtaining blood cultures from two sites
- C. Administering Ciprofloxacin (Cipro) 400 mg IV
- D. Inserting an Acetaminophen (Tylenol) rectal suppository
Correct Answer: B
Rationale: In a patient with probable bacterial pneumonia and sepsis, the priority intervention is to obtain blood cultures from two sites before initiating antibiotic therapy. This is crucial to identify the causative organism and guide appropriate antibiotic treatment. Administering antibiotics without obtaining cultures first can interfere with accurate results. Performing a chest x-ray and administering acetaminophen can be done after obtaining blood cultures as they are important but not as urgent as identifying the causative organism in sepsis.
A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents?
- A. Do not let this prescription run out.
- B. The medication may cause gingival hyperplasia.
- C. Periodic serum drug levels are needed.
- D. Watch for excessive facial hair growth.
Correct Answer: A
Rationale: The correct teaching for the child and parents when a child is prescribed baclofen via an intrathecal pump is to not let the prescription run out. Abrupt discontinuation of intrathecal baclofen can lead to severe effects like high fever, altered mental status, and rebound spasticity and muscle rigidity. It is crucial for the parents to ensure there is always an adequate supply of this medication to prevent these adverse effects. Choices B and D are incorrect because gingival hyperplasia and hirsutism are side effects associated with phenytoin (Dilantin), not baclofen. Choice C is incorrect as serum drug levels are not typically monitored for intrathecal medications.
A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
- A. Assist with active range of motion (ROM).
- B. Observe for agitation and paranoia.
- C. Give muscle relaxants as needed to reduce spasms.
- D. Use simple words and phrases to explain procedures.
Correct Answer: A
Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.
While auscultating a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
- A. Inspiratory crackles at the bases
- B. Expiratory wheezes in both lungs
- C. Abnormal lung sounds in the apices of both lungs
- D. Pleural friction rub in the right and left lower lobes
Correct Answer: A
Rationale: The correct answer is 'Inspiratory crackles at the bases.' Crackles are low-pitched, bubbling sounds typically heard during inspiration, which aligns with the nurse's finding. Expiratory wheezes are high-pitched sounds and are not consistent with the described auscultation findings. The lower third of both lungs refers to the bases, not the apices, so option C is incorrect. Pleural friction rubs are grating sounds heard during both inspiration and expiration, unlike the described finding of only hearing the sounds during inhalation in the lower third of both lungs.