1. A nurse assesses a 42-year-old client at a health clinic. The client is married and lives in
a condo with their spouse. The client reports having frequent voiding and pain when they
pass urine. The nurse asks whether the client has to go to the bathroom frequently
during the night and they respond, "Yes, usually twice or more." The client had an
episode of diarrhea one week ago. They weigh 136 kilograms and report having difficulty
cleansing their perineum after voiding or passing stool.
2. Which data finding(s) indicates the nursing diagnosis of impaired urinary elimination?
Select all that apply.
3. Weight
4. Age 42 years
5. Episode of diarrhea
6. Painful urination
7. Frequent urination at night- ANS-Painful urination
8. frequent urination at night
9.
10. A nurse on a surgical unit is caring for a client who had surgery yesterday to repair a
broken leg. The client is restless, grimacing, and groaning. The client's heart rate and
blood pressure are elevated. The nurse notices that the client's pain medication has not
yet been administered this morning. What part of this situation should the nurse reflect
upon? - ANS-The delay in administration of the pain medication
11.
12. Based on the nursing diagnosis of impaired gas exchange, which intervention is most
appropriate for the client? - ANS-Initiate supplemental oxygen
13.
14. Click to specify the assessment findings that indicate the client's condition is improving
or declining.
15. 1. Respiratory rate 22 per minute
16. 2. Oxygen saturation 82%
17. 3. Temperature 99.2°F (37.3°C)
18. 4. Client states "I feel like I can breathe better."- ANS-1. Improving
19. 2. Declining
20. 3. Improving
21. 4. Improving
22.
23. For each nursing intervention, identify if the intervention is a direct or indirect care
measure.
24. 1. Initiating an intravenous line to provide hydration
25. 2. Repositioning the client every 2 hours to prevent pressure injuries
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