Question

A nurse is assessing a client's abdomen and notes that it is firm, distended, and tender over the symphysis pubis. Which of the following findings should the nurse recognize as the most likely cause?

Answer 1

Correct Answers:

Urinary retention

Rationale :

✨ Urinary retention causes urine to accumulate in the bladder when the client cannot empty it completely.

✨ An overfilled bladder becomes firm, distended, and tender directly above the symphysis pubis.

✨ Additional findings may include urinary hesitancy, frequent small voids, overflow dribbling, or an inability to urinate.

✨ The nurse should assess recent urine output and use a bladder scanner to determine the volume of retained urine.

✨ Prompt treatment is necessary because prolonged retention can cause pain, urinary tract infection, bladder damage, and renal impairment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Assist the client into the high-Fowler position with a bedpan.

Rationale :

✳️ The high-Fowler position places the postoperative client upright and uses gravity to support movement of stool toward the rectum.

✳️ This position resembles the natural sitting posture used for defecation and improves the effectiveness of abdominal muscles.

✳️ Proper positioning is especially important because opioid analgesics reduce gastrointestinal motility and commonly cause constipation.

✳️ The nurse should also provide privacy, allow adequate time, encourage fluids and mobility, and administer prescribed bowel medications.

✳️ Placing the client upright with a bedpan is the safest and most effective option for promoting bowel elimination among the choices.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

"What strategies helped you to feel in control of your health before this surgery?"

Rationale :

💎 This open-ended statement encourages the client to identify previous coping strategies that were helpful during stressful health situations.

💎 It acknowledges the client’s possible feelings of fear, altered body image, vulnerability, and loss of control without minimizing them.

💎 The question keeps the communication focused on the client rather than the nurse’s personal experiences or assumptions.

💎 The client’s response can guide the nurse in planning gradual participation in stoma observation and ostomy care.

💎 Supporting autonomy and effective coping can increase the client’s confidence and eventual self-care independence.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

35

Rationale :

✍️The prescribed enteral nutrition volume is 840 mL over 24 hours.

✍️Formula

✔️Total volume ÷ total infusion time.

✔️840 mL ÷ 24 hr

🔶35 mL/hr.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Confusion

Rationale :

🎯 Older adults with a urinary tract infection can develop acute confusion or delirium instead of classic urinary manifestations.

🎯 Age-related changes in immune response may reduce expected findings such as fever, dysuria, and localized discomfort.

🎯 The client may also demonstrate agitation, lethargy, appetite loss, falls, weakness, or sudden functional decline.

🎯 The nurse should compare the client’s mental status with baseline and assess for other possible causes of delirium.

🎯 Rapid identification is important because untreated infection can progress to urosepsis and serious systemic complications.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

"I will include a lot of cheese and ice cream in my diet."

Rationale :

🧿 Cheese and ice cream contain little or no dietary fiber, which is needed to increase stool bulk and promote bowel movement.

🧿 Consuming large quantities of high-fat dairy products can slow gastrointestinal motility and worsen constipation.

🧿 These foods can also replace healthier fiber-rich choices such as fruits, vegetables, legumes, and whole grains.

🧿 The client should combine adequate fiber with sufficient water intake and regular physical activity to maintain normal bowel function.

🧿 This statement indicates a need for further teaching because increasing cheese and ice cream can contribute to hard, infrequent stools.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers

Blank 1 Correct Option: a urinary tract infection (UTI)
Blank 2 Correct Option: urinary retention

Rationale :

🍊 The client has urinary retention, as shown by suprapubic pain, lower-abdominal pressure, incomplete bladder emptying, and an elevated post-void residual of 250 mL.

🍊 Removal of 925 mL of urine by straight catheterization further confirms that a substantial amount of urine had accumulated in the bladder.

🍊 Retained urine creates urinary stasis, allowing bacteria to multiply because the bladder is not being emptied effectively.

🍊 The client’s urinary frequency, tachycardia, and reported temperature of 38.7°C increase concern for a developing urinary tract infection, although urinalysis and culture results are still pending.

🍊 The nurse should monitor for fever, cloudy or foul-smelling urine, dysuria, worsening suprapubic pain, and changes in mental status, while ensuring the prescribed diagnostic testing is completed.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Caffeinated beverages

Rationale :

✨ Caffeinated beverages stimulate the gastrointestinal tract and increase movement of intestinal contents.

✨ Rapid intestinal transit reduces the amount of time available for the colon to absorb water.

✨ The resulting excess fluid in the stool can cause loose stools, urgency, and diarrhea.

✨ Coffee, energy drinks, strong tea, and some soft drinks are common sources of caffeine.

✨ Clients experiencing diarrhea should limit caffeine and choose water or oral rehydration fluids to prevent dehydration.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Urinary tract infection (UTI)

Rationale :

✳️ A urinary tract infection can cause inflammation and irritation of the bladder and urinary tract lining.

✳️ Inflamed urinary tissue may bleed slightly, resulting in pink or blood-tinged urine.

✳️ An indwelling catheter increases infection risk because it provides a direct route for microorganisms to enter the bladder.

✳️ Additional findings can include cloudy urine, foul odor, suprapubic discomfort, fever, and changes in mental status.

✳️ The nurse should report the finding and obtain prescribed urinalysis and urine culture testing.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Ensure the oxygen flowmeter is set to the correct liters (L) to be delivered.

Rationale :

💎 The nurse must first confirm that oxygen is being delivered at the prescribed flow rate.

💎 An incorrect flow setting can cause inadequate oxygen delivery or excessive oxygen administration.

💎 The flowmeter directly controls the number of liters of oxygen the client receives each minute.

💎 Correct oxygen delivery is especially urgent because the client is currently experiencing difficulty breathing.

💎 The nurse should then reassess respiratory effort, oxygen saturation, device placement, and the client’s response.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is assessing a client's abdomen and notes that it is firm, distended, and tender over the symphysis pubis. Which of the following findings should the nurse recognize as the most likely cause?

3 :
A client who is 2 days postoperative after a colostomy is struggling to look at his stoma when the nurse attempts to engage him in ostomy care. Which of the following statements is most therapeutic for the nurse to make?

5 :
A nurse is caring for an 85-year-old client with a urinary tract infection (UTI). Which of the following clinical manifestations is unique to older adult clients with a UTI?

6 :
A nurse is educating a client on measures that can be taken to prevent constipation. Which of the following statements indicates the need for further teaching?

7 :
A nurse is caring for a client who is being treated in the emergency department (ED).

Correct Answers

8 :
A nurse is teaching a client about foods and beverages that can cause diarrhea. Which of the following should the nurse include in the teaching?

9 :
A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the urine collection bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

10 :
A nurse is instructing a nursing student on the steps for administering supplemental oxygen to a client who is currently experiencing difficulty breathing. Which of the following interventions should be identified as the priority?

QLexNursing

1 : A nurse is assessing a client's abdomen and notes that it is firm, distended, and tender over the symphysis pubis. Which of the following findings should the nurse recognize as the most likely cause?

3 : A client who is 2 days postoperative after a colostomy is struggling to look at his stoma when the nurse attempts to engage him in ostomy care. Which of the following statements is most therapeutic for the nurse to make?

5 : A nurse is caring for an 85-year-old client with a urinary tract infection (UTI). Which of the following clinical manifestations is unique to older adult clients with a UTI?

6 : A nurse is educating a client on measures that can be taken to prevent constipation. Which of the following statements indicates the need for further teaching?

7 : A nurse is caring for a client who is being treated in the emergency department (ED).

Correct Answers

8 : A nurse is teaching a client about foods and beverages that can cause diarrhea. Which of the following should the nurse include in the teaching?

9 : A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the urine collection bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

10 : A nurse is instructing a nursing student on the steps for administering supplemental oxygen to a client who is currently experiencing difficulty breathing. Which of the following interventions should be identified as the priority?

1 :
A nurse is assessing a client's abdomen and notes that it is firm, distended, and tender over the symphysis pubis. Which of the following findings should the nurse recognize as the most likely cause?

3 :
A client who is 2 days postoperative after a colostomy is struggling to look at his stoma when the nurse attempts to engage him in ostomy care. Which of the following statements is most therapeutic for the nurse to make?

5 :
A nurse is caring for an 85-year-old client with a urinary tract infection (UTI). Which of the following clinical manifestations is unique to older adult clients with a UTI?

6 :
A nurse is educating a client on measures that can be taken to prevent constipation. Which of the following statements indicates the need for further teaching?

7 :
A nurse is caring for a client who is being treated in the emergency department (ED).

8 :
A nurse is teaching a client about foods and beverages that can cause diarrhea. Which of the following should the nurse include in the teaching?

9 :
A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the urine collection bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

10 :
A nurse is instructing a nursing student on the steps for administering supplemental oxygen to a client who is currently experiencing difficulty breathing. Which of the following interventions should be identified as the priority?