🫁 Overflow incontinence occurs when the bladder becomes overdistended and is unable to empty completely, causing frequent leakage of small amounts of urine.

🫁 The client’s palpable bladder indicates urinary retention with bladder distention, which is a key finding of overflow incontinence.

🫁 Postoperative clients are at increased risk for urinary retention due to effects of anesthesia, medications (especially opioids), and decreased bladder muscle tone.

🫁 When the bladder becomes too full, urine leaks out involuntarily because the pressure exceeds the bladder’s ability to hold urine.

🫁 Clients with overflow incontinence often report:

Dribbling urine

Incomplete bladder emptying

Frequent small voids

Weak urine stream

🫁 The nurse should assess bladder volume, monitor intake and output, and evaluate for urinary retention.

🫁 Management may include interventions such as bladder scanning, scheduled toileting, or catheterization if prescribed.

🫁 Therefore, frequent small urine leakage with a distended palpable bladder indicates overflow incontinence.

❌ Incorrect Answers

Stress

🫁 Stress incontinence occurs when increased abdominal pressure causes urine leakage, such as with coughing, sneezing, or lifting.

🫁 It is not associated with bladder distention or urinary retention.

Urge

🫁 Urge incontinence involves a sudden, strong need to urinate followed by involuntary urine loss.

🫁 The bladder is usually not enlarged or palpable.

Functional

🫁 Functional incontinence occurs when a person cannot reach or use the toilet due to physical or cognitive limitations.

🫁 It does not involve bladder overfilling or urinary retention.

🫁 Clients with extensive burn injuries may experience body image disturbance, grief, anxiety, and depression related to changes in appearance and function.

🫁 Support groups allow burn survivors to connect with others who have experienced similar challenges and provide emotional encouragement.

🫁 Peer support can help clients develop coping strategies and improve acceptance of physical changes.

🫁 Burn recovery involves not only physical healing but also psychological adjustment to scars, altered appearance, and possible lifestyle changes.

🫁 Support groups provide a safe environment where clients can discuss feelings about self-esteem, relationships, and social interactions.

🫁 The nurse should recognize that emotional healing may continue long after wounds have healed.

🫁 Encouraging participation in support resources promotes adaptation, confidence, and improved quality of life.

🫁 Therefore, recommending a burn injury support group is an appropriate therapeutic nursing intervention.

❌ Incorrect Answers

"It is okay to not want to touch the burned areas of your body."

🫁 Avoiding the burned areas may reinforce negative feelings and delay adjustment to body changes.

🫁 The client should be encouraged to gradually participate in wound care and body acceptance activities as tolerated.

"Cosmetic surgery should be performed within the next year to be effective."

🫁 Cosmetic or reconstructive procedures are individualized and may not be performed within a specific timeframe.

🫁 Surgery timing depends on wound healing, scar maturation, and the client’s overall condition.

"Reconstructive surgery can completely restore your previous appearance."

🫁 Reconstructive surgery can improve function and appearance but cannot always completely restore the client’s previous appearance.

🫁 Providing unrealistic expectations may interfere with emotional adjustment and coping.

✅ Have noticed any dark, tarry stools

🫁 The client’s laboratory findings indicate iron deficiency anemia (Hgb 8.1 g/dL, Hct 27%, low MCV of 70 fL, and low transferrin saturation).

🫁 Crohn’s disease can cause chronic gastrointestinal inflammation and bleeding, leading to iron loss.

🫁 Dark, tarry stools (melena) may indicate occult gastrointestinal bleeding, which can contribute to iron deficiency.

🫁 The nurse should assess for signs of blood loss because ongoing bleeding can worsen anemia.

🫁 Identifying the source of iron loss helps guide treatment and prevent recurrence.

🫁 The client’s fatigue, pallor, tachycardia, and shortness of breath are consistent with decreased oxygen-carrying capacity from anemia.

🫁 Therefore, asking about dark, tarry stools is an appropriate assessment question.

✅ IV iron dextran

🫁 The client has findings consistent with iron deficiency anemia, likely related to Crohn’s disease and possible impaired intestinal absorption after small bowel resection.

🫁 Iron deficiency is supported by:

Low hemoglobin

Low hematocrit

Low MCV (microcytic anemia)

Low transferrin saturation

🫁 After small bowel surgery, oral iron absorption may be reduced, making IV iron replacement more effective.

🫁 Iron dextran IV provides iron directly into circulation to support red blood cell production.

🫁 Correcting iron deficiency improves hemoglobin levels and helps reduce symptoms such as fatigue, weakness, and shortness of breath.

🫁 The nurse should monitor for allergic reactions during IV iron administration.

🫁 Iron therapy should continue until iron stores and hemoglobin levels improve.

🫁 Therefore, IV iron dextran is an appropriate treatment option for this client.

❌ Incorrect Options:

❌ Are having numbness in their hands and feet

🫁 Numbness and tingling are associated with vitamin B12 deficiency, which causes neurologic symptoms.

🫁 The client’s findings indicate iron deficiency anemia rather than B12 deficiency.

❌ Have a family member with an anemia disorder

🫁 Family history is important for inherited anemias such as sickle cell disease or thalassemia.

🫁 The client’s low MCV and low transferrin saturation indicate acquired iron deficiency.

❌ Have recently been exposed to radiation or insecticides

🫁 Radiation and chemical exposure may contribute to bone marrow suppression.

🫁 The client’s laboratory findings do not indicate aplastic anemia or toxic marrow injury.

❌ Subcutaneous vitamin B12 injections

🫁 Vitamin B12 injections are used for pernicious anemia or severe B12 deficiency.

🫁 The client’s B12 level is within the expected range and findings point toward iron deficiency.

❌ Oral folic acid

🫁 Folic acid treats folate deficiency, which causes macrocytic anemia with an increased MCV.

🫁 This client has a low MCV, indicating microcytic iron deficiency anemia.

❌ Cyclosporine

🫁 Cyclosporine is an immunosuppressant used for certain autoimmune conditions and transplant patients.

🫁 It does not treat iron deficiency anemia.

🫁 Acute gastritis causes inflammation and irritation of the gastric mucosa, requiring gradual reintroduction of food after being NPO.

🫁 Gelatin is part of a clear liquid diet and is gentle on the stomach while providing a small amount of calories and hydration.

🫁 Clear liquids help assess the client’s ability to tolerate oral intake before advancing to more solid foods.

🫁 Gelatin is bland and does not contain substances that stimulate excessive gastric acid production.

🫁 The nurse should initially avoid foods and beverages that may irritate the stomach lining or worsen gastritis symptoms.

🫁 Introducing easily tolerated foods decreases the risk of nausea, vomiting, abdominal pain, and gastric discomfort.

🫁 The nurse should monitor the client for tolerance before progressing the diet as prescribed.

🫁 Therefore, gelatin is the most appropriate choice when resuming oral intake after acute gastritis.

❌ Incorrect Answers :

Lemonade

🫁 Lemonade is acidic due to its citrus content and can irritate the inflamed gastric lining.

🫁 Acidic beverages may worsen epigastric pain and gastric discomfort.

Tomato soup

🫁 Tomato soup is acidic and may increase irritation of the gastric mucosa.

🫁 It may worsen symptoms in clients recovering from gastritis.

Black coffee

🫁 Coffee can stimulate gastric acid secretion and may aggravate gastritis symptoms.

🫁 Caffeinated beverages should generally be avoided during acute gastric irritation.

✅ Frequently monitor pulse oximetry

🫁 The client has acute pancreatitis, indicated by significantly elevated amylase and lipase levels, severe abdominal pain, vomiting, and systemic symptoms.

🫁 Pancreatitis can cause respiratory complications such as pleural effusion, atelectasis, and acute respiratory distress syndrome (ARDS).

🫁 The client’s oxygen saturation has decreased to 92%, and respiratory rate has increased to 26/min, indicating possible respiratory compromise.

🫁 Frequent pulse oximetry monitoring helps detect worsening oxygenation early.

✅ Frequently monitor blood glucose

🫁 The pancreas produces insulin, and inflammation from pancreatitis can impair pancreatic endocrine function.

🫁 Acute pancreatitis can lead to hyperglycemia due to reduced insulin production and increased stress hormones.

🫁 Monitoring glucose levels helps identify metabolic complications.

🫁 Early detection allows prompt management of abnormal glucose levels.

✅ Assess for Chvostek's sign and Trousseau's sign

🫁 The client’s calcium level is decreased (8.5 mg/dL), which can occur with acute pancreatitis.

🫁 Pancreatic inflammation can cause fat necrosis, which binds calcium and leads to hypocalcemia.

🫁 Hypocalcemia increases the risk of neuromuscular irritability.

🫁 Chvostek’s and Trousseau’s signs assess for manifestations of hypocalcemia, such as facial twitching and muscle spasms.

❌ Keep the client in a supine position

🫁 Supine positioning may worsen abdominal discomfort and increase pressure on the inflamed pancreas.

🫁 Clients with pancreatitis are often positioned with the head of bed elevated or leaning forward to reduce pain.

❌ Prepare to administer an enema

🫁 Enemas are not indicated for acute pancreatitis.

🫁 The priority interventions focus on reducing pancreatic stimulation, managing pain, and supporting fluid and respiratory status.

✅ Place a nasogastric tube

🫁 The client has severe nausea, vomiting, abdominal distention, and inability to tolerate oral intake.

🫁 A nasogastric tube may be used to decompress the stomach and reduce pancreatic stimulation.

🫁 Gastric decompression can decrease vomiting and abdominal discomfort.

✅ Administer oxygen via nasal cannula

🫁 The client has decreased oxygen saturation (92%), tachypnea, and signs of systemic illness.

🫁 Oxygen therapy improves tissue oxygenation and reduces the risk of complications from hypoxemia.

🫁 Respiratory monitoring is essential because pancreatitis can progress to respiratory failure.

✅ Prepare to administer IV fluids

🫁 Acute pancreatitis causes significant fluid shifts due to inflammation and third-spacing.

🫁 The client has signs of hypovolemia:

Blood pressure 91/55 mm Hg

Heart rate 109/min

Cool, clammy skin

🫁 IV fluids help restore circulating volume and support organ perfusion.

✅ Make the client NPO

🫁 Keeping the client nothing by mouth (NPO) reduces pancreatic stimulation and decreases secretion of digestive enzymes.

🫁 This allows the pancreas time to rest and heal during acute inflammation.

🫁 Nutrition is later advanced as symptoms improve and the client can tolerate intake.

🫁 The red triage tag indicates a client who requires immediate treatment due to life-threatening but potentially survivable injuries.

🫁 The child has a respiratory rate of 8/min, which indicates severe respiratory compromise and possible airway or breathing failure.

🫁 In mass casualty triage, breathing abnormalities are a priority because airway and breathing problems can quickly become fatal.

🫁 The child is unresponsive to verbal commands and only responds to painful stimuli, indicating a decreased level of consciousness and possible neurologic injury.

🫁 A Glasgow Coma Scale (GCS) assessment would likely indicate significant impairment requiring urgent intervention.

🫁 The child may require immediate airway support, oxygen therapy, or other lifesaving measures.

🫁 Although the injuries are severe, the child has signs of life and may benefit from rapid intervention.

🫁 Therefore, the appropriate triage classification is red (immediate priority).

❌ Incorrect Answers

Yellow

🫁 Yellow tags are assigned to clients with serious injuries who are stable enough to wait for treatment.

🫁 This child has unstable breathing and altered consciousness, requiring immediate care.

Green

🫁 Green tags are for clients with minor injuries who can walk and wait for care.

🫁 An unresponsive child with respiratory compromise does not meet green criteria.

Black

🫁 Black tags are used for clients who are deceased or have injuries incompatible with survival.

🫁 This child has signs of life and may survive with immediate intervention.

🫁 The cerebellum controls balance, coordination, posture, and fine motor movements, so a tumor in this area can impair the client’s ability to walk safely.

🫁 Clients with cerebellar tumors are at increased risk for ataxia (uncoordinated movements), dizziness, and falls due to impaired coordination and balance.

🫁 Assisting with ambulation is the priority because preventing injury from falls is an immediate safety concern.

🫁 The nurse should assess the client’s gait, balance, strength, and need for assistive devices before allowing independent mobility.

🫁 Providing assistance during movement promotes safety while maintaining as much independence as possible.

🫁 Fall prevention measures, such as keeping the environment free of hazards and using call assistance, are essential.

🫁 Preventing falls reduces the risk of additional injury, especially in clients with neurologic impairment.

🫁 Therefore, assisting with ambulation is the priority nursing action for a client with a cerebellar tumor.

❌ Incorrect Answers

Facilitate retention of facts by repeating instructions.

🫁 Repeating instructions may help clients with cognitive impairment but is not the priority concern with a cerebellar tumor.

🫁 Cerebellar tumors primarily affect coordination and balance rather than memory.

Place the client in a darkened room.

🫁 A darkened room is useful for clients with conditions such as migraines or photophobia.

🫁 It does not address the major safety concern of impaired coordination and fall risk.

Speak slowly and clearly.

🫁 Speaking slowly and clearly may assist clients with communication difficulties.

🫁 It does not address the immediate risk caused by cerebellar dysfunction.

🫁 Active tuberculosis requires airborne precautions because Mycobacterium tuberculosis spreads through tiny airborne droplet nuclei that can remain suspended in the air.

🫁 The client should be placed in a negative-pressure airborne infection isolation room (AIIR) with the door kept closed to prevent contaminated air from escaping.

🫁 Keeping the door closed helps maintain proper airflow and reduces the risk of transmission to healthcare workers and visitors.

🫁 Healthcare workers entering the room should wear a fit-tested N95 respirator or higher-level respiratory protection, not a standard surgical mask.

🫁 Airborne precautions are required until the client is no longer considered infectious based on clinical improvement and provider/public health guidance.

🫁 The nurse should limit unnecessary movement of the client outside the room to reduce spread of airborne organisms.

🫁 Proper environmental control is essential because TB can spread even when direct contact with respiratory secretions does not occur.

🫁 Therefore, maintaining a closed door is an appropriate action when caring for a client with active tuberculosis.

❌ Incorrect Answers :

Remain 1 m (3 feet) away from the client when providing care.

🫁 Maintaining a specific distance is used for some droplet precautions, not airborne precautions.

🫁 TB transmission occurs through airborne particles that can travel beyond 3 feet.

Apply a surgical mask before entering the client's room.

🫁 A surgical mask does not provide adequate protection against airborne TB particles.

🫁 The nurse should wear an N95 respirator before entering the room.

Place a "no visitors" sign on the client's door.

🫁 Visitors are not automatically prohibited but should follow airborne precautions.

🫁 Appropriate education and respiratory protection should be provided to visitors.

🫁 Epoetin alfa is an erythropoiesis-stimulating agent (ESA) that stimulates the bone marrow to produce more red blood cells.

🫁 Before administering epoetin, the nurse should review the client’s hemoglobin (Hgb) level to determine if the medication is appropriate and safe.

🫁 Epoetin is prescribed to treat anemia associated with chemotherapy by increasing red blood cell production and improving oxygen-carrying capacity.

🫁 The medication should be held and the provider notified if hemoglobin rises above the recommended target range because of the risk of complications.

🫁 Excessive increases in red blood cell production can increase blood viscosity and raise the risk of hypertension, stroke, myocardial infarction, and thromboembolic events.

🫁 Monitoring hemoglobin levels helps evaluate the effectiveness of therapy and guides dosage adjustments.

🫁 The nurse should also monitor blood pressure because epoetin can worsen hypertension.

🫁 Therefore, reviewing the client’s hemoglobin level before administration is the priority nursing action.

❌ Incorrect Answers :

Use the Z-track method when administering the medication.

🫁 The Z-track method is commonly used for irritating intramuscular medications such as iron dextran.

🫁 Epoetin is usually administered subcutaneously or intravenously, not using the Z-track technique.

Shake the vial for 30 seconds prior to withdrawing the medication.

🫁 Epoetin should not be shaken because vigorous handling can damage the protein structure of the medication.

🫁 The vial should be gently handled and inspected before administration.

Ensure the client is not taking iron supplements while on this medication.

🫁 Iron supplementation may be needed because epoetin increases red blood cell production, which requires adequate iron stores.

🫁 The nurse should monitor iron levels rather than prevent iron supplementation.