MC The client has a continuous bladder irrigation (CBI). When you assess the client, you find the urine collection bag is empty after 1 hour. Your initial action is to
A. Disconnect the catheter and instill 50 mL irrigant with firm pressure.
B. Observe if the irrigating solution is infusing into the bladder.
C. Irrigate the catheter by inserting a fluid-filled syringe into the injection port.
D. Change the catheter as it is probably occluded.
B
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The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times,
he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.
The nurse wants to determine if a patient is experiencing tremors. When performing this assessment, for what should the nurse observe?
1. shaking 2. jerky movements 3. rhythmic movements 4. fasciculations
A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway should identify this outcome as being which of the following?
1. An unattainable goal 2. A variance 3. An error in care planning 4. An error in intervention implementation
While performing a home visit with an elderly patient, the nurse notices that the patient's dress is less tidy than in previous visits, and she finds an open orange juice container in the pantry cabinet instead of the refrigerator and a roll of paper towe
a. Begin rearranging the patient's storage, and show her how it needs to be done. b. Raise her voice, and tell the patient that this is not acceptable. c. Complete a Mini-Mental State Examination (MMSE) or Short Geriatric Depression Scale (GDS). d. Realize that elderly patients do things differently.