Fund 4

A nurse is caring for a patient with diarrhea who is at risk for skin breakdown. Which of the following factors best explains why this patient is at increased risk for impaired skin integrity?

A 72-year-old male patient with diabetes presents with a non-healing ulcer on his foot that has been present for 3 months. The nurse classifies this wound as: Vital signs: Temperature: 98.6°F (37°C) Pulse: 82 beats per minute Respiration: 18 breaths per minute Blood pressure: 130/80 mmHg

A 45-year-old female patient presents with a deep sacral wound that exposes bone and muscle. The nurse documents this pressure injury as: Vital signs: Temperature: 99.1°F (37.3°C) Pulse: 90 beats per minute Respiration: 16 breaths per minute Blood pressure: 125/75 mmHg

A 65-year-old male presents with a surgical incision that is healing by primary intention. During a follow-up assessment, the nurse observes well-approximated edges with no signs of infection. Based on this observation, which phase of wound healing is most likely occurring? Vital signs: Temperature: 98.7°F (37.1°C) Pulse: 76 beats per minute Respiration: 18 breaths per minute Blood pressure: 124/78 mmHg Physical assessment: Surgical incision site is clean with no erythema, swelling, or discharge. Edges are approximated with sutures intact.

A 55-year-old male with a history of hypertension presents with a large burn wound that has been healing for 4 weeks. The nurse notices the wound is lighter in color with minimal granulation tissue and no signs of infection. Which phase of healing is the wound most likely in? Vital signs: Temperature: 98.4°F (36.9°C) Pulse: 82 beats per minute Respiration: 20 breaths per minute Blood pressure: 138/85 mmHg Physical assessment: Burn wound is clean with reduced granulation tissue. Scar tissue is forming with no signs of infection or inflammation.

Answer: D. Maturation phase Rationale: The maturation phase of wound healing occurs approximately 3 weeks after the initial injury and may continue for months or years. During this phase, collagen is remodeled, and the wound becomes lighter in color as scar tissue forms. This matches the current description of the patient’s wound. The hemostasis (Option A) and inflammatory (Option B) phases occur much earlier in the healing process. The proliferation phase (Option C) involves the formation of granulation tissue, which is minimal in this case.

A 65-year-old female with diabetes presents with a foot ulcer. The nurse notes significant swelling around the wound, which appears red and warm to the touch. The patient reports mild pain and difficulty walking. What factor is likely impairing wound healing in this patient? Vital signs: Temperature: 99.0°F (37.2°C) Pulse: 82 beats per minute Respiration: 20 breaths per minute Blood pressure: 130/82 mmHg Physical assessment: The foot ulcer is surrounded by significant edema, with localized redness and warmth. The wound shows no signs of drainage, and the surrounding tissue is firm to palpation.

A 30-year-old female patient presents with a deep pressure injury on her sacrum. The nurse notes the formation of granulation tissue within the wound. What is the most important intervention to promote healing during this phase? Vital signs: Temperature: 99.0°F (37.2°C) Pulse: 84 beats per minute Respiration: 16 breaths per minute Blood pressure: 120/80 mmHg Physical assessment: Granulation tissue present in sacral wound with no signs of infection. Surrounding skin is intact.

A 58-year-old male with a history of smoking and peripheral vascular disease presents with a non-healing ulcer on his left lower leg. The nurse notes poor capillary refill and pallor in the surrounding tissue. What systemic factor is most likely affecting wound healing? Vital signs: Temperature: 97.9°F (36.6°C) Pulse: 74 beats per minute Respiration: 18 breaths per minute Blood pressure: 135/80 mmHg Physical assessment: The leg ulcer shows delayed healing, with poor granulation tissue. Surrounding skin is pale and cool to the touch, with capillary refill greater than 3 seconds.

A nurse is caring for a 60-year-old patient with a surgical wound that is healing slowly. The patient has a history of diabetes mellitus and is currently taking corticosteroids. Which factors could be contributing to delayed wound healing in this patient? (Select all that apply)

A 45-year-old female post-surgery patient presents with complaints of increased pain, swelling, and purulent drainage from her abdominal incision 5 days after surgery. Her temperature is elevated, and her wound shows signs of redness and warmth around the incision site. Which of the following should be the nurse’s priority action? Vital signs: Temperature: 101.4°F (38.6°C) Pulse: 94 beats per minute Respiration: 20 breaths per minute Blood pressure: 128/84 mmHg Physical assessment: Abdominal incision is red, swollen, and warm to touch with purulent drainage. The patient reports increased pain and discomfort.

A 60-year-old male patient with a history of diabetes presents with a large abdominal wound that shows signs of dehiscence. The nurse observes that the wound edges are separating, but no organs are protruding. Which of the following should be the nurse's priority intervention? Vital signs: Temperature: 98.9°F (37.2°C) Pulse: 88 beats per minute Respiration: 18 breaths per minute Blood pressure: 132/86 mmHg Physical assessment: Abdominal wound shows partial dehiscence with wound edges separating. No evisceration noted, and the patient reports mild discomfort.

A 68-year-old male, 24 hours post-op from abdominal surgery, presents with a large amount of fresh bleeding on his dressing and a rapidly forming hematoma around the incision site. Which of the following should be the nurse’s priority intervention? Vital signs: Temperature: 98.8°F (37.1°C) Pulse: 112 beats per minute Respiration: 22 breaths per minute Blood pressure: 90/60 mmHg Physical assessment: Abdominal dressing is soaked with fresh blood, and a large hematoma is present. The patient appears pale and reports dizziness.

A 72-year-old female with a history of diabetes mellitus reports sudden sharp abdominal pain 5 days after surgery. Upon inspection, the nurse observes partial dehiscence of the surgical wound with serosanguineous drainage. What is the nurse’s priority action? Vital signs: Temperature: 99.0°F (37.2°C) Pulse: 98 beats per minute Respiration: 18 breaths per minute Blood pressure: 135/78 mmHg Physical assessment: The abdominal wound shows partial dehiscence with serosanguineous drainage. The patient reports increased discomfort but no visible evisceration.

A nurse is educating an older adult patient about factors that increase their risk for skin breakdown. Which of the following factors is most associated with increased risk for impaired skin integrity in this age group?

A 75-year-old male with a history of diabetes presents with a sacral wound covered with black eschar. The nurse is unable to assess the depth of the wound. What is the priority nursing action? Vital signs: Temperature: 98.6°F (37°C) Pulse: 85 beats per minute Respiration: 18 breaths per minute Blood pressure: 140/85 mmHg Physical assessment: Sacral wound covered with dry, black eschar. Surrounding skin is intact, and there is no visible drainage or erythema.

A 68-year-old female patient with a chronic leg wound expresses anxiety and fear about her wound not healing. She is concerned about how her wound appears to others and how it affects her self-image. Which of the following should be the nurse’s priority intervention based on Maslow’s Hierarchy of Needs? Vital signs: Temperature: 98.5°F (36.9°C) Pulse: 72 beats per minute Respiration: 18 breaths per minute Blood pressure: 130/85 mmHg Physical assessment: Chronic leg wound with serous drainage, granulation tissue present, and no signs of infection. The patient expresses concern over her appearance and self-worth.

A 55-year-old male patient with a history of diabetes has a foot wound covered with black eschar. The nurse is assessing the wound and planning interventions. Based on the nursing process, what is the priority intervention? Vital signs: Temperature: 99.1°F (37.3°C) Pulse: 85 beats per minute Respiration: 20 breaths per minute Blood pressure: 145/90 mmHg Physical assessment: Foot wound covered with black eschar, no drainage, and surrounding skin appears cool to the touch. The patient reports no pain.

An 80-year-old female patient with a history of immobility due to a hip fracture is at high risk for developing pressure injuries. She is also malnourished and has been refusing meals. Which of the following interventions should be the nurse's priority to prevent pressure injury development? Vital signs: Temperature: 98.3°F (36.8°C) Pulse: 78 beats per minute Respiration: 16 breaths per minute Blood pressure: 118/72 mmHg Physical assessment: The patient is alert but frail, with limited mobility. The skin appears dry, with no current signs of pressure injuries. The patient is refusing meals and fluid intake is minimal.

A 70-year-old male, bedridden after a hip fracture, has redness over his sacrum that does not blanch when pressed. The nurse suspects a stage 1 pressure injury. What is the priority nursing action? Vital signs: Temperature: 98.9°F (37.2°C) Pulse: 75 beats per minute Respiration: 18 breaths per minute Blood pressure: 130/85 mmHg Physical assessment: Non-blanchable redness over the sacrum, intact skin, with warmth compared to surrounding tissue. The patient reports mild discomfort.

A 65-year-old female patient with advanced Alzheimer's disease has a blister on her right heel that has ruptured, exposing partial-thickness skin loss. The nurse suspects a stage 2 pressure injury. What is the priority intervention? Vital signs: Temperature: 99.0°F (37.2°C) Pulse: 80 beats per minute Respiration: 16 breaths per minute Blood pressure: 128/78 mmHg Physical assessment: A shallow open ulcer with partial-thickness skin loss on the right heel, surrounding skin intact with no signs of infection. The patient is non-verbal and does not express discomfort.

A 72-year-old male patient recovering from abdominal surgery has a surgical wound with serosanguineous drainage. During a dressing change, the nurse notices that the wound edges are starting to separate (dehiscence). What is the priority nursing action based on safety and risk reduction? Vital signs: Temperature: 98.7°F (37.1°C) Pulse: 90 beats per minute Respiration: 18 breaths per minute Blood pressure: 125/80 mmHg Physical assessment: Abdominal wound with separating edges and light serosanguineous drainage. No signs of infection present.

A 55-year-old female post-op patient reports feeling that "something has given way" while coughing. The nurse assesses the wound and finds complete evisceration of the abdominal contents. What is the nurse's priority action? Vital signs: Temperature: 98.6°F (37°C) Pulse: 110 beats per minute Respiration: 24 breaths per minute Blood pressure: 100/58 mmHg Physical assessment: The abdominal wound is completely open with visible evisceration of internal organs. The patient is anxious and reports significant discomfort.

A 75-year-old female, who is bedridden due to a stroke, presents with redness over her sacral area. The nurse notices that the redness does not blanch when pressed. What is the priority action for the nurse? Vital signs: Temperature: 98.7°F (37.1°C) Pulse: 80 beats per minute Respiration: 16 breaths per minute Blood pressure: 130/85 mmHg Physical assessment: Non-blanchable erythema on the sacral area, with intact skin. No drainage or odor present. The patient reports mild discomfort.

QuestionA 68-year-old male with a history of immobility due to spinal cord injury is assessed for pressure injuries. The nurse observes a stage 2 pressure injury on his right heel, with partial-thickness skin loss and a shallow open ulcer. Which of the following is the nurse's priority intervention? Vital signs: Temperature: 98.2°F (36.8°C) Pulse: 72 beats per minute Respiration: 18 breaths per minute Blood pressure: 122/80 mmHg Physical assessment: A shallow ulcer with partial-thickness skin loss on the right heel, surrounded by intact skin. No signs of infection or drainage.

A 60-year-old female patient with dementia is admitted for malnutrition and has developed a stage 3 pressure injury on her sacrum. The wound presents with full-thickness skin loss and visible subcutaneous tissue. What is the priority nursing intervention for this patient? Vital signs: Temperature: 99.1°F (37.3°C) Pulse: 85 beats per minute Respiration: 20 breaths per minute Blood pressure: 110/70 mmHg Physical assessment: A stage 3 pressure injury on the sacrum, with full-thickness skin loss and exposed subcutaneous tissue. Moderate drainage noted, but no signs of infection.

A 78-year-old female who is bedridden due to advanced dementia has been admitted to the hospital with malnutrition and dehydration. The nurse notices redness over her heels that does not blanch when pressed. Which intervention should be the priority to prevent further skin breakdown? Vital signs: Temperature: 98.4°F (36.9°C) Pulse: 72 beats per minute Respiration: 18 breaths per minute Blood pressure: 120/76 mmHg Physical assessment: Redness over heels that is non-blanchable. The patient is malnourished and dehydrated. No drainage or skin breakdown present yet.

A 65-year-old male post-stroke patient is admitted to the hospital with left-sided paralysis. He is unable to reposition himself independently. During the skin assessment, the nurse finds a stage 1 pressure injury on his sacrum. What is the priority intervention for this patient? Vital signs: Temperature: 98.6°F (37°C) Pulse: 80 beats per minute Respiration: 18 breaths per minute Blood pressure: 135/82 mmHg Physical assessment: Stage 1 pressure injury on the sacrum with intact skin and non-blanchable redness. The patient has limited mobility and is unable to turn himself.

A 64-year-old female patient with a large pressure injury on her sacrum is receiving wound care. The wound is in the proliferative phase of healing, with healthy granulation tissue present. The patient expresses frustration about her limited ability to perform activities of daily living (ADLs). What is the priority nursing intervention? Vital signs: Temperature: 98.2°F (36.8°C) Pulse: 82 beats per minute Respiration: 18 breaths per minute Blood pressure: 135/85 mmHg Physical assessment: Sacral wound with healthy granulation tissue, serous drainage present, and the patient is experiencing reduced mobility and frustration about her ADLs.

A 62-year-old male patient is recovering from surgery and has a surgical wound on his abdomen with moderate serosanguineous drainage. The nurse notes that the dressing is moist but not saturated. The patient expresses concern about seeing his wound for the first time during the dressing change. Based on Maslow’s Hierarchy of Needs and the nursing process, what is the priority nursing intervention? Physical assessment: Age: 62 years Serosanguineous drainage on the dressing, moderate amount, wound edges approximated, no signs of infection.

A 68-year-old male patient with diabetes is recovering from an abdominal surgery. The nurse is preparing to remove his surgical dressing, which is adhered to the skin. The patient expresses concern about pain during the dressing change. Based on Maslow’s Hierarchy of Needs and the nursing process, what is the priority intervention? Vital signs: Temperature: 98.6°F (37°C) Pulse: 80 beats per minute Respiration: 18 breaths per minute Blood pressure: 130/85 mmHg Physical assessment: Surgical incision with dry edges, dressing adhered to the skin, no signs of infection or drainage. The patient reports mild discomfort with movement.

A 72-year-old female patient with a stage 2 pressure injury on her sacrum is due for a dressing change. The nurse observes that the dressing is saturated with serous drainage. What is the priority nursing intervention? Vital signs: Temperature: 98.9°F (37.2°C) Pulse: 76 beats per minute Respiration: 16 breaths per minute Blood pressure: 125/80 mmHg Physical assessment: Stage 2 pressure injury with moderate serous drainage, surrounding skin is intact, and there is no sign of infection.

A 65-year-old male patient with a non-healing pressure injury is being considered for negative pressure wound therapy (NPWT) after other treatments have failed. Based on the nursing process and safety and risk reduction, what is the priority nursing action before initiating NPWT? Vital signs: Temperature: 98.6°F (37°C) Pulse: 76 beats per minute Respiration: 18 breaths per minute Blood pressure: 132/78 mmHg Physical assessment: Stage 4 pressure injury with minimal drainage, no signs of infection, exposed tendons and bone.

A 70-year-old male patient with chronic lower back pain is prescribed local heat therapy to relieve muscle tension and promote relaxation. Based on Maslow’s Hierarchy of Needs and the nursing process, what is the priority nursing assessment before applying the heat therapy? Vital signs: Temperature: 98.7°F (37.1°C) Pulse: 75 beats per minute Respiration: 16 breaths per minute Blood pressure: 132/78 mmHg Physical assessment: Chronic lower back pain, no open wounds, no signs of infection or inflammation in the area. Patient reports pain level 5/10.

A 55-year-old male with a history of diabetes mellitus is admitted with a stage 2 pressure injury on his sacrum. As part of his care, you are engaging in reflective practice to improve wound care management and evaluating the effectiveness of the plan of care. Based on Maslow's Hierarchy of Needs and the nursing process, what is the priority action in reflecting on and improving your wound care practices? Vital signs: Temperature: 98.6°F (37°C) Pulse: 78 beats per minute Respiration: 18 breaths per minute Blood pressure: 128/80 mmHg Physical assessment: Sacral pressure injury with partial-thickness skin loss, no infection present, wound bed moist and pink, minimal serous drainage. Blood glucose: 180 mg/dL (elevated) Patient reports pain level: 3/10 Question: What is the priority reflective question to ask yourself as you evaluate your wound care practices for this patient?

A nurse is evaluating a care plan for a patient who is recovering from a urinary tract infection (UTI). Which of the following findings would indicate that the patient's urinary function is improving?

A nurse is evaluating the care plan for a patient with urinary retention. Which of the following findings would require an adjustment to the care plan?

A nurse is caring for four patients with different urinary elimination concerns. Which patient should the nurse prioritize for care based on their condition?

A nurse is caring for multiple patients who are experiencing bowel elimination issues. Which patient should the nurse see first?

A nurse is caring for four patients with bowel elimination concerns. Which patient should the nurse prioritize for immediate care?

A nurse is reviewing the bowel elimination patterns of four patients. Which patient should the nurse assess first?

A nurse is caring for four patients. Which patient should the nurse assess first?

A nurse is reviewing the charts of four patients. Which patient should the nurse prioritize for care?

A nurse is assigned to care for four patients. Which patient should the nurse see first?

A nurse is caring for four patients with bowel elimination issues. Which patient should be assessed first?

A nurse is performing an abdominal assessment on four patients. Which patient should the nurse assess first?

A nurse is caring for four patients with abnormal abdominal findings. Which patient should the nurse assess first?

A nurse is performing a physical assessment on four patients with gastrointestinal complaints. Which patient should the nurse prioritize?

A nurse is performing an abdominal assessment on four patients. Which patient should the nurse assess first?

A nurse is assessing four patients with gastrointestinal issues. Which patient should the nurse prioritize for care?

A nurse is caring for four patients with abnormal abdominal findings. Which patient requires immediate intervention?

A nurse is conducting abdominal assessments on multiple patients. Which patient should the nurse prioritize for immediate intervention based on inspection and auscultation findings?

A nurse is performing an abdominal assessment on multiple patients. Which patient should the nurse assess first?

A nurse is assessing the bowel sounds of four patients. Which patient should the nurse prioritize for care?

A nurse is performing an abdominal assessment on four patients. Which finding should the nurse prioritize for further investigation?

A nurse is caring for four patients with diarrhea. Which patient should the nurse assess first?

A nurse is assessing four patients with a history of diarrhea. Which patient should the nurse prioritize for further evaluation and intervention?

A nurse is caring for four patients with chronic diarrhea. Which patient should the nurse see first?

A nurse is caring for four patients who report symptoms of flatulence. Which patient should the nurse prioritize for further evaluation?

A nurse is preparing to administer enemas to four patients. Which patient should the nurse prioritize for intervention?

A nurse is caring for four patients requiring enemas. Which patient should the nurse assess first?

A nurse is preparing to administer enemas to four patients. Which patient’s care should the nurse prioritize?

A nurse is administering enemas to several patients. Which patient requires immediate intervention during the procedure?

A nurse is caring for four patients with bowel incontinence. Which patient’s care should be prioritized?

A nurse is caring for four patients with bowel incontinence. Which patient requires immediate intervention?

A nurse is managing the care of multiple patients who require bowel-training programs or are using drainage systems for bowel incontinence. Which patient should the nurse prioritize for immediate intervention?

A nurse is implementing bowel-training programs for four patients. Which patient’s care should be prioritized based on their condition?

A nurse is implementing bowel-training programs for four patients. Which patient’s care should be prioritized based on their condition?

A nurse is caring for four patients with nasogastric tubes. Which patient should the nurse assess first?

A nurse is overseeing the bowel-training programs for four patients. Which patient should the nurse prioritize for a review of the bowel-training program?

A nurse is caring for multiple patients with nasogastric (NG) tubes and bowel diversions. Which patient should the nurse prioritize for immediate intervention?

A nurse is managing the care of several patients with nasogastric (NG) tubes. Which patient requires the nurse's immediate attention?

A nurse is caring for four patients with nasogastric (NG) tubes. Which patient’s care should the nurse prioritize?

A nurse is caring for several patients with bowel diversions and nasogastric (NG) tubes. Which patient’s care should the nurse address first?

A nurse is caring for several patients who have undergone surgeries involving ostomies. Which patient should the nurse prioritize for immediate intervention?

A nurse is assessing multiple patients with new ostomies. Which patient’s condition warrants immediate nursing intervention?

A nurse is reviewing care plans for four patients with bowel diversions. Which patient’s care plan should be prioritized?

A nurse is educating patients with ostomies on postoperative care. Which patient should the nurse prioritize for further education?

A nurse is caring for a patient who recently had an ostomy surgery. The patient expresses concerns about body image, permanent body changes, and social activities. Which intervention should the nurse prioritize?

A nurse is working with a patient who recently underwent ostomy surgery and is having difficulty accepting the permanent body changes. The patient reports feelings of isolation and refuses to participate in social activities. What should be the nurse’s priority intervention?

A patient with a new ostomy is hesitant to participate in self-care and expresses concerns about intimacy and social relationships. Which nursing action should be prioritized?

A nurse is assisting a patient with coping strategies after an ostomy surgery. The patient is concerned about body image changes and has been avoiding social gatherings. What action should the nurse prioritize?

A 72-year-old female presents to the emergency department with complaints of urinary incontinence and hematuria. She has a history of chronic urinary tract infections (UTIs) and diabetes mellitus. Upon assessment, she reports frequent urination, nocturia, and a sensation of incomplete bladder emptying. Which of the following interventions should the nurse prioritize using Maslow's Hierarchy of Needs and the nursing process to address the client’s current condition?

A 58-year-old male patient presents with complaints of nocturia, urinary frequency, and difficulty starting urination. Upon assessment, the nurse notes that the patient has a history of benign prostatic hyperplasia (BPH) and has been prescribed tamsulosin. His vital signs are: BP: 138/84 mmHg HR: 82 bpm RR: 18 breaths/min Temp: 36.8°C (98.2°F) The nurse should prioritize which of the following interventions to address the patient's elimination needs?

A 75-year-old female patient has been admitted to the hospital with a urinary tract infection (UTI) and reports symptoms of urinary urgency, dysuria, and hematuria. Her vital signs are: BP: 132/78 mmHg HR: 88 bpm RR: 20 breaths/min Temp: 38.4°C (101.1°F) The nurse is implementing the care plan for the patient. Which nursing action should be prioritized based on the nursing process and Maslow's Hierarchy of Needs?

A 40-year-old male presents with complaints of urinary incontinence, stating that he experiences involuntary urine leakage when sneezing or laughing. He also reports difficulty controlling urination during physical activity. Vital signs are: BP: 120/80 mmHg HR: 72 bpm RR: 16 breaths/min Temp: 37.0°C (98.6°F) Which intervention should the nurse prioritize to address the patient’s stress incontinence?

Patient Profile: Name: John Smith Age: 68 years Gender: Male Chief Complaint: Increased urinary frequency Medical History: Hypertension, benign prostatic hyperplasia (BPH), and recent travel Current Symptoms: Frequent urination during the day (every 1-2 hours) Waking 3-4 times during the night to urinate Straining during urination and a weak urine stream A feeling of incomplete bladder emptying Medications: Tamsulosin (Flomax) for BPH Lisinopril for hypertension Physical Assessment: Vital Signs: BP: 142/90 mmHg HR: 78 bpm RR: 16 breaths/min Temp: 37.1°C (98.8°F) Bladder Scan: Postvoid residual volume of 200 mL Urine Analysis Results: Appearance: Clear Specific Gravity: 1.015 No hematuria or bacteriuria detected Which of the following is the most appropriate initial nursing intervention based on the patient’s complaints of increased urinary frequency?

A nurse is caring for a patient who has just returned from a hemodialysis session. The patient reports dizziness and generalized weakness. What is the nurse’s priority action?

Question: A nurse is caring for a patient with an incontinent urinary diversion who uses a two-piece external appliance. The patient reports frequent leakage around the stoma site and is concerned about odor and skin irritation. What is the nurse’s priority action?

A patient with a continent urinary diversion is concerned about the appearance of their stoma and refuses to participate in stoma care. What should the nurse prioritize in this situation?

A patient with end-stage renal disease is receiving hemodialysis through an arteriovenous (AV) fistula. The nurse notices that the patient’s fistula site appears swollen and slightly red. The patient also reports mild pain at the site. What is the nurse’s priority action?

A nurse is monitoring a patient with a new continent urinary diversion for signs of complications. The nurse notes that the stoma appears swollen and edematous, and the patient reports mild discomfort. What is the nurse’s priority action?

A nurse is caring for a patient who had an Indiana pouch (continent urinary diversion) created 3 days ago. The patient reports that it is difficult to catheterize the stoma due to the presence of mucus. What is the nurse’s priority action?

A nurse is caring for a patient with a temporary urologic stent after the removal of renal calculi. What should the nurse prioritize in the care of this patient?

A patient who had an indwelling catheter removed reports a burning sensation during the first urination. The nurse recognizes that this is a normal response. What should the nurse prioritize in teaching the patient?

A nurse is caring for a patient after the removal of an indwelling catheter that was in place for 7 days. The patient reports difficulty voiding and has not urinated for 8 hours since the catheter was removed. What is the nurse's priority action?

A nurse is removing an indwelling urinary catheter from a patient. After the catheter is removed, what is the nurse’s priority action?

A patient with a suprapubic catheter and catheter valve reports difficulty using the valve due to decreased sensation of bladder fullness. Which intervention should the nurse prioritize?

A nurse is caring for a patient with a suprapubic catheter and a catheter valve instead of a drainage bag. The patient has been instructed to release urine from the valve every 3 to 4 hours. What is the nurse’s priority action if the patient reports feeling bladder fullness but is unable to release urine through the valve?

A nurse is caring for a male patient with urinary incontinence who has been prescribed a single-use disposable external urine collection device. The patient reports mild skin irritation in the pubic area. What should the nurse prioritize to prevent further skin breakdown?

A nurse is educating a patient on the proper use of a disposable external urine collection device for managing urinary incontinence. Which instruction should the nurse prioritize to ensure the device is used effectively?

A patient is using a reusable external urine collection device to manage chronic urinary incontinence. The nurse notices that the patient is developing erythema and irritation around the genital area. What should the nurse prioritize to prevent further skin damage?

A nurse is caring for a patient who is using a single-use disposable external urine collection device to manage urinary incontinence. The nurse notices that the device is leaking, and the patient’s skin around the pubic area is becoming irritated. What should be the nurse’s priority action?

A patient with urinary incontinence is using an external urine collection device. The nurse notes that the device has not been collecting urine efficiently and the patient is experiencing discomfort. What should the nurse prioritize to ensure proper function of the device?

A 75-year-old female patient with urinary incontinence is prescribed an external urine collection device. The nurse notices that the device has been leaking, and the patient’s skin around the genital area is red and irritated. What should the nurse prioritize to prevent further skin damage?

A nurse is caring for an older male patient with urinary incontinence and frequent skin breakdown. The healthcare provider orders the use of an external urine collection device to manage the patient's incontinence. What action should the nurse prioritize to prevent complications related to skin integrity?

A nurse is caring for a male patient with urinary incontinence who is at high risk for developing incontinence-associated dermatitis (IAD). The healthcare provider has ordered an external urine collection device to manage urinary incontinence. Which action should the nurse prioritize when applying the external urine collection device?

A nurse is caring for a patient with incontinence-associated dermatitis (IAD) who has developed erythema and skin irritation around the perineal area. Which action should the nurse prioritize to promote healing and prevent further skin breakdown?

A nurse is discussing noninvasive treatments for urinary incontinence with a 72-year-old female patient who reports occasional stress incontinence. Which intervention should the nurse prioritize to improve the patient’s condition?

A nurse is caring for an 80-year-old patient with urinary incontinence who is at risk for incontinence-associated dermatitis (IAD). Which action should the nurse prioritize to prevent skin breakdown in this patient?

A 60-year-old female patient with urge incontinence reports frequent, sudden urges to urinate and occasional leakage before reaching the bathroom. What is the nurse’s priority intervention to help manage the patient’s symptoms?

A 72-year-old patient with functional incontinence reports frequent episodes of urine loss because she cannot reach the bathroom in time due to limited mobility. Which intervention should the nurse prioritize to prevent further incontinent episodes?

A 72-year-old patient with functional incontinence reports frequent episodes of urine loss because she cannot reach the bathroom in time due to limited mobility. Which intervention should the nurse prioritize to prevent further incontinent episodes?

A nurse is assessing a 65-year-old male patient with diabetes who is experiencing overflow incontinence. The patient reports dribbling urine and feeling like his bladder never fully empties. What action should the nurse prioritize to assess the patient's condition?

A nurse is caring for an 82-year-old female patient with stress incontinence. The patient reports feeling embarrassed and socially isolated due to frequent episodes of urine leakage when she coughs or sneezes. Which intervention should the nurse prioritize to improve the patient’s continence and quality of life?

A sexually active 30-year-old female presents with dysuria, urinary frequency, and cloudy urine. Which of the following patient education points should the nurse prioritize to prevent recurrent urinary tract infections (UTIs)?

A 70-year-old postmenopausal patient with an indwelling urinary catheter reports discomfort and cloudy urine. Which action should the nurse prioritize to prevent further complications?

A nurse is assessing a 65-year-old patient with diabetes who presents with symptoms of urinary frequency, urgency, and cloudy urine with a foul odor. Which action should the nurse prioritize?

A patient recovering from surgery is experiencing weak urinary stream and reports incomplete bladder emptying. Which intervention should the nurse prioritize to promote urinary elimination and strengthen bladder control?

A patient with reduced mobility is using a bedpan for urination. The nurse notices that the patient has difficulty voiding and is uncomfortable using the bedpan. What should the nurse prioritize to improve the patient’s comfort and ability to void?

A patient reports frequent episodes of stress incontinence. The nurse has taught the patient how to perform pelvic floor muscle training (Kegel exercises). Which action should the nurse prioritize to evaluate the effectiveness of the teaching?

A nurse is caring for a 78-year-old patient with limited mobility who is experiencing urinary retention. Which action should the nurse prioritize to promote urination and prevent complications?

A nurse is providing aftercare instructions to a patient following urodynamic studies. Which statement by the patient indicates an understanding of the aftercare?

A patient is scheduled for urodynamic studies to assess bladder function and voiding patterns. Which of the following should the nurse include in the patient's pre-procedure teaching?

A nurse is performing point-of-care urine testing for a patient with diabetes mellitus to monitor glucose levels in the urine. Which of the following steps should the nurse follow to ensure accurate results?

A nurse is tasked with obtaining a urine specimen for culture from a 6-month-old infant. Which method is most appropriate for this procedure?

A patient with a urinary diversion is instructed to perform a 24-hour urine collection. Which of the following statements by the patient indicates an understanding of the procedure?

A nurse is preparing to collect a urine specimen for culture and sensitivity from a patient with a urinary diversion (urostomy). Which of the following steps should the nurse follow to collect the specimen? Select all that apply.

A 40-year-old female patient is being instructed on how to collect a clean-catch midstream urine specimen. Which statement by the patient indicates a need for further teaching?

A 3-year-old female is being assessed for readiness for toilet training. The mother states that her child is showing an interest in the potty and can verbally indicate when she needs to go but still has occasional daytime accidents. Which of the following should the nurse prioritize when assessing the child’s readiness for toilet training?

A 75-year-old male patient presents with complaints of nocturia and urinary frequency. He reports urinating 5-6 times a night and feeling like he can never fully empty his bladder. His vital signs are: BP: 150/90 mmHg HR: 72 bpm RR: 18 breaths/min Temp: 36.7°C (98°F) What should the nurse prioritize in managing this patient’s symptoms?

A 55-year-old female patient with a history of diabetes mellitus presents with complaints of urinary frequency and dark-colored urine. She states that she has been under stress and has not been drinking much water lately. Vital signs are: BP: 140/85 mmHg HR: 80 bpm RR: 20 breaths/min Temp: 37.5°C (99.5°F) What should be the nurse’s priority in addressing this patient’s urinary elimination issue?

A 35-year-old female patient complains of frequent urination, dark yellow urine, and lower abdominal pain. She mentions that she has recently been under stress and has not been drinking enough water. Her vital signs are: BP: 128/82 mmHg HR: 88 bpm RR: 18 breaths/min Temp: 37.8°C (100°F) What is the most appropriate initial nursing intervention for this patient?

A 45-year-old male with a history of diabetes mellitus presents with complaints of urinary retention, frequent urination, and occasional dribbling of urine. His physical assessment reveals a distended bladder. His vital signs are: BP: 140/85 mmHg HR: 76 bpm RR: 16 breaths/min Temp: 36.9°C (98.4°F) What should the nurse prioritize to address the patient's urinary retention?