A 70-year-old man arrives in the emergency department and says, "I haven't urinated in 24 hours. I feel like I have to go, but I can't." What care should the nurse anticipate providing first?
a. Emergency preparation for an intravenous pyelogram (IVP)
b. Emergency preparation for a cystoscopy
c. STAT insertion of an indwelling catheter
d. STAT administration of IV fluids
ANS: C
First, the man must be assisted to empty his bladder to avoid rupture or other complications. IV fluids will further add to his need to urinate. Preparation for tests would wait until he is safe from immediate harm.
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The nurse is assessing a client's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for compl
a. "Are you worried about addiction to pain pills?" b. "Do you attach any spiritual meaning to pain?" c. "How high would you say your pain tolerance is?" d. "What pain rating would be acceptable to you?"
A 48-year-old woman tells the nurse, "I missed my period last month. Am I in menopause?" The nurse knows that at which point is a woman considered to be menopausal?
a. Her periods have stopped for 1 year. b. Her periods have been irregular and light for 12 months. c. She has symptoms of vasomotor instability. d. She experiences symptoms of decreased estrogen, such as dyspareunia.
Reinforce your identity and position to the mothers each time you provide care
Indicate whether the statement is true or false
When assessing a client with cervical cancer who had a total abdominal hysterectomy yesterday, you obtain the following data. Which information has the most immediate implications for planning of the client's care?
a. Fine crackles are audible at the lung bases b. The client's right calf is swollen, and she reports calf tenderness c. The client uses the patient-controlled analgesia pump every 30 minutes d. Urine in the collection bag is amber and clear