A nurse is assessing an older patient for the possible cause of his acute urinary incontinence. Which actions by the nurse are most important? (Select all that apply.)
a. Asking when his last normal bowel movement was
b. Monitoring his intake and output
c. Determining if he has been screened for prostatic hypertrophy
d. Asking him if he awakens during the night to urinate
e. Measuring his abdominal girth
A, C, D
Constipation or fecal impaction as well as an enlarged prostate gland (causing frequent nighttime urination) are commonly overlooked causes of incontinence. Intake and output and abdominal girth are not related to possible causes of incontinence.
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The nurse is working with a 50-year-old patient with emphysema who smokes and eats poorly. Which of the following should she mention to the patient regarding her disease? Select all that apply
A) The disease may be reversible if the irritant causing inflammation can be identified. B) Lung volume reduction surgery may increase her respiratory function. C) Smoking cessation can slow the progress of COPD. D) Improving her nutritional state could increase her respiratory muscle strength.
The nurse is aware that which of the following results when an increased concentration of hydrogen ions occurs within body fluids?
a. They become acidic. b. They become alkaline. c. Oxygen ions are released into the blood. d. Carbon ions are retained.
A patient's injury has initiated an immune response that involves inflammation. What are the first cells to arrive at a site of inflammation?
A) Eosinophils B) Red blood cells C) Lymphocytes D) Neutrophils
The nurse is administering prescribed sodium nitroprusside (Nipride) intravenously to a client who has shock. Which nursing intervention is a priority when administering this medication?
a. Ask if the client has chest pain every 30 minutes. b. Assess the client's blood pressure every 15 minutes. c. Monitor the client's urinary output every hour. d. Observe the client's extremities every 4 hours.