The nurse teaches a 90-year-old male patient these steps he can take to minimize urinary retention: ensure good fluid intake, massage the bladder area, and run water while he is voiding. The primary reason for this teaching is prevention of which of the following?
A) Urinary incontinence
B) Urinary tract infections
C) Constipation
D) Prostatic hypertrophy
B
Feedback:
Urinary retention puts the older adult at risk for urinary tract infections.
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When prioritizing a patient's care plan based on Maslow's Hierarchy of needs, the nurse's first priority would be:
A) Allowing the family to see a newly admitted patient B) Ambulating the patient in the hallway C) Administering pain medication D) Teaching the patient to self-administer insulin
The nurse preparing to administer penicillin to a client with syphilis teaches the client to report symptoms of Jarisch-Herxheimer reaction, including:
1. Fine red rash over the entire body, accompanied by itching. 2. Dizziness, fainting, low blood pressure, and bradycardia. 3. Fever, headache, myalgia, and significant chancre changes. 4. Extreme chest pain lasting more than several minutes.
On auscultation, the nurse detects a heart murmur. The nurse knows that a heart murmur indicates:
1. the valves are not closing correctly. 2. the pericardium is inflamed. 3. there is a decrease in pacemaker cells. 4. a loud ventricular gallop.
A vaginal exam for a laboring multipara client who is 42 weeks' gestation reveals the following information: 4 cm, minimal effacement, -2 station
Which clinical factors would affect the clinical management decision not to rupture membranes with an AmniHook? a. Vaginal dilation b. Client is a multipara c. Presenting part is at –2 station d. Gestational age