After the catheter is in place, the ED physician writes orders to discharge M.B. with
instructions to see his primary care provider (PCP) on the following day. It is your
responsibility to give discharge instructions. Outline your care plan.
What will be an ideal response?
• Explain how to empty the Foley catheter without contaminating the drainage bag.
• Instruct M.B. to keep the bag below his waist to prevent reflux of urine into the bladder.
• Explain how to check the tubing for mechanical obstruction if urine ceases to collect in the bag.
• Instruct him when to contact the physician or go directly to the ED—for example, when urine is the
consistency or color of tomato juice, when there is no urinary drainage, or when pain is unrelieved
by acetaminophen (Tylenol) as per labeled product instructions. Explain to the patient that
acetaminophen intake should not exceed 3 g (3000 mg) per 24 hours in a patient with a healthy
liver, to avoid liver damage and toxicity.
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The statement that provides the best rationale for the nursing intervention of monitoring the severely
depressed client closely during antidepressant therapy is a. as depression lifts, physical energy becomes available to carry out a plan for suicide. b. suicide may be precipitated by a variety of internal and external events. c. suicidal clients have difficulty using social supports. d. suicide is an impulsive act.
The physician orders a pneumococcal vaccination for a 70-year-old patient. How does the nurse best describe this immunization?
1. Antibody response is lower in the older person 2. Cellular response in the immune system increases 3. Aging causes a decreased antibody production to self 4. Increased production of IgE leads to greater risk of pneumonia
Which health team members set and adjust the oxygen flow rate?
a. The doctor and nurse b. The doctor and respiratory therapist c. The nurse and respiratory therapist d. The nurse and nursing assistant
A nurse assesses a patient who is taking pramlintide (Symlin) with mealtime insulin. Which of these findings should require immediate follow-up by the nurse?
A) Skin rash B) Sweating C) Itching D) Pedal edema