Question

A nurse is reviewing the urinary output over the past 24 hours for a client with pneumonia. The client's medical record notes documentation of a total of 400 mL of urine output for this time period. Upon assessment, the client's skin is dry and the BP is 98/56. What is the nurse's next step?

Answer 1

Correct Answers:

Contact the healthcare provider to report the client's urinary output from the last 24 hours.

Rationale :

♦️ A total urine output of 400 mL in 24 hours is abnormally low and is consistent with oliguria, which generally requires prompt evaluation.

♦️ The client's dry skin and BP of 98/56 mm Hg further suggest fluid volume deficit and decreased circulating volume.

♦️ Reduced circulating volume can decrease renal perfusion, potentially causing or worsening acute kidney injury if it is not corrected promptly.

♦️ The nurse should notify the healthcare provider because the client requires further evaluation of hydration status, renal function, and possible fluid replacement.

♦️ Prompt reporting allows interventions to occur before the client develops worsening hypotension, electrolyte abnormalities, or renal dysfunction.

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Answer 2

Correct Answers:

It focuses on prevention and relief of symptoms and/or disease.

Rationale :

🖍️ Palliative care focuses on preventing and relieving pain, symptoms, and suffering associated with serious illness.

🖍️ The goal is to improve the client's quality of life rather than focusing exclusively on curing the underlying disease.

🖍️ Palliative care addresses physical, emotional, psychosocial, and spiritual needs of clients and their families.

🖍️ It can be provided at any stage of serious illness and may occur simultaneously with curative or disease-directed treatments.

🖍️ Common priorities include management of pain, dyspnea, nausea, anxiety, fatigue, and other distressing symptoms.

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Answer 3

Correct Answers:

Urinary tract infection

Rationale :

✍️ Visible particles, sediment, or debris in urine can occur when bacteria, white blood cells, mucus, and cellular material accumulate during a urinary tract infection.

✍️ An indwelling urinary catheter significantly increases the risk for a catheter-associated urinary tract infection (CAUTI) because it provides a pathway for microorganisms to enter the urinary tract.

✍️ Additional findings can include cloudy or foul-smelling urine, fever, suprapubic discomfort, and leukocytosis depending on the client's condition.

✍️ The nurse should assess the client for systemic and urinary manifestations and maintain a closed drainage system using aseptic technique.

✍️ If infection is suspected, the provider might prescribe a urinalysis and urine culture to identify the causative organism.

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Answer 4

Correct Answers:

"I will call for pain medication before the previous dose wears off."

Rationale :

✏️ Taking prescribed analgesia before severe pain returns provides more effective pain control than waiting until pain becomes intense.

✏️ Maintaining therapeutic analgesic levels can prevent the pain cycle from becoming difficult to control after major abdominal surgery.

✏️ Adequate pain relief promotes deep breathing, coughing, ambulation, and participation in postoperative care.

✏️ Effective pain management can therefore reduce complications such as atelectasis, pneumonia, and immobility-related problems.

✏️ The client's statement demonstrates appropriate understanding of proactive pain management rather than unnecessary avoidance or overuse of medication.

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Answer 5

Correct Answers:

Decreased muscle tone

Rationale :

🌻 Decreased muscle tone commonly occurs as death approaches because muscular strength and neurological responsiveness progressively decline.

🌻 The client may develop difficulty swallowing, reduced ability to move, loss of sphincter control, and relaxation of facial muscles.

🌻 Progressive weakness reflects decreasing circulation, oxygenation, and metabolic activity during the dying process.

🌻 Other expected findings include decreased urine output, weak peripheral pulses, altered breathing patterns, and decreased consciousness.

🌻 Recognizing these changes allows the nurse to prepare the family and focus care on comfort and dignity.

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Answer 6

Correct Answers:

Total Intake-1300 mL, Total Output = 800 mL

Rationale :

🏵️ Oral intake = 10 oz × 30 mL = 300 mL.

🏵️ IV intake = 1,000 mL.

🏵️ Total intake = 300 mL + 1,000 mL = 1,300 mL.

🏵️ Urinary catheter output = 800 mL.

🏵️ Final answer: Intake = 1,300 mL; Output = 800 mL.

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Answer 7

Correct Answers:

A perceived stressor alerts or stimulates the central nervous system.

Rationale :

✳️ The alarm reaction stage is the first stage of general adaptation syndrome (GAS).

✳️ During this stage, recognition of a stressor stimulates the central nervous system and sympathetic nervous system.

✳️ The hypothalamus activates the fight-or-flight response, resulting in release of catecholamines such as epinephrine and norepinephrine.

✳️ Physiologic responses can include increased heart rate, increased blood pressure, increased respiratory rate, and heightened alertness.

✳️ This immediate response prepares the body to respond rapidly to a perceived threat or stressor.

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Answer 8

Correct Answers:

Increase the client's fluid intake.

Rationale :

🧿 Adequate fluid intake helps soften stool and facilitates movement of fecal material through the gastrointestinal tract.

🧿 Clients on bed rest are particularly susceptible to constipation because immobility decreases intestinal motility and abdominal muscle activity.

🧿 Increasing fluids, when not contraindicated by cardiac or renal conditions, can reduce hard, dry stools and straining.

🧿 Constipation management should also include adequate dietary fiber, mobility when permitted, and regular toileting habits.

🧿 Increasing fluid consumption is therefore an appropriate initial nursing intervention for immobility-related constipation.

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Answer 9

Correct Answers:

"The incision looks like it is healing."

Rationale :

🌸 The client's ability to look at and discuss the surgical incision demonstrates increasing acceptance of the physical changes resulting from mastectomy.

🌸 Positive adaptation to altered body image often begins when the client can acknowledge and realistically evaluate the changed body part or surgical site.

🌸 Recognizing that the incision is healing indicates that the client is focusing on recovery and adaptation rather than avoiding the affected area.

🌸 Continued supportive communication can help the client gradually incorporate the physical change into their self-concept and identity.

🌸 This statement therefore reflects healthier adjustment than avoidance, social withdrawal, or rejection of the client's previous life.

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Answer 10

Correct Answers:

Administer the prescribed morphine dose for pain control.

Rationale :

♠️ The client's respiratory rate of 16 breaths/min is within the expected adult range and does not indicate respiratory depression.

♠️ Morphine is commonly used in hospice care to relieve moderate-to-severe pain and can also decrease the sensation of dyspnea.

♠️ Hospice care emphasizes prompt relief of pain and suffering, making comfort a major priority when medication has already been prescribed.

♠️ Withholding an indicated opioid because of an unfounded fear of respiratory depression can result in unnecessary suffering and poor symptom control.

♠️ The nurse should administer the prescribed morphine and subsequently reassess the client's pain level, respiratory status, sedation, and comfort.

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QLexNursing

1 :
A nurse is reviewing the urinary output over the past 24 hours for a client with pneumonia. The client's medical record notes documentation of a total of 400 mL of urine output for this time period. Upon assessment, the client's skin is dry and the BP is 98/56. What is the nurse's next step?

2 :
A nurse is teaching a class about palliative care. The nurse should include which of the following concepts in the teaching plan regarding palliative care?

3 :
A nurse is caring for a client who has an indwelling urinary catheter and notes particles in the urinary drainage bag. Which of the following would the nurse suspect?

4 :
A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

5 :
A nurse is caring for a terminally ill client. Which assessment finding would be an indication of impending death?

7 :
A nurse is teaching a class about the stages of general adaptation syndrome (GAS). The nurse should include that which of the following is the first physiological response that occurs?

8 :
A nurse is caring for a client who is on bed rest and is experiencing constipation. Which of the following interventions should the nurse implement?

9 :
A nurse is providing discharge teaching to a client following a mastectomy. Which of the following client statements indicates an improvement in body image?

10 :
The nurse is assessing a client receiving hospice care who has a respiratory rate of 16 breaths/minute and complains of severe pain. What is the best action for the nurse to take?

QLexNursing

1 : A nurse is reviewing the urinary output over the past 24 hours for a client with pneumonia. The client's medical record notes documentation of a total of 400 mL of urine output for this time period. Upon assessment, the client's skin is dry and the BP is 98/56. What is the nurse's next step?

2 : A nurse is teaching a class about palliative care. The nurse should include which of the following concepts in the teaching plan regarding palliative care?

3 : A nurse is caring for a client who has an indwelling urinary catheter and notes particles in the urinary drainage bag. Which of the following would the nurse suspect?

4 : A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

5 : A nurse is caring for a terminally ill client. Which assessment finding would be an indication of impending death?

7 : A nurse is teaching a class about the stages of general adaptation syndrome (GAS). The nurse should include that which of the following is the first physiological response that occurs?

8 : A nurse is caring for a client who is on bed rest and is experiencing constipation. Which of the following interventions should the nurse implement?

9 : A nurse is providing discharge teaching to a client following a mastectomy. Which of the following client statements indicates an improvement in body image?

10 : The nurse is assessing a client receiving hospice care who has a respiratory rate of 16 breaths/minute and complains of severe pain. What is the best action for the nurse to take?

1 :
A nurse is reviewing the urinary output over the past 24 hours for a client with pneumonia. The client's medical record notes documentation of a total of 400 mL of urine output for this time period. Upon assessment, the client's skin is dry and the BP is 98/56. What is the nurse's next step?

2 :
A nurse is teaching a class about palliative care. The nurse should include which of the following concepts in the teaching plan regarding palliative care?

3 :
A nurse is caring for a client who has an indwelling urinary catheter and notes particles in the urinary drainage bag. Which of the following would the nurse suspect?

4 :
A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

5 :
A nurse is caring for a terminally ill client. Which assessment finding would be an indication of impending death?

7 :
A nurse is teaching a class about the stages of general adaptation syndrome (GAS). The nurse should include that which of the following is the first physiological response that occurs?

8 :
A nurse is caring for a client who is on bed rest and is experiencing constipation. Which of the following interventions should the nurse implement?

9 :
A nurse is providing discharge teaching to a client following a mastectomy. Which of the following client statements indicates an improvement in body image?

10 :
The nurse is assessing a client receiving hospice care who has a respiratory rate of 16 breaths/minute and complains of severe pain. What is the best action for the nurse to take?