A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

Remove the catheter and palpate the client’s bladder for residual distention.

Allow the bladder to empty completely or up to 1,000 mL of urine.

Clamp the catheter for thirty minutes and then resume draining.

Remove the catheter and replace with an indwelling catheter.

Answer and Explanation

The Correct Answer is B

Choice A: Remove the catheter and palpate the client’s bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.

Choice B: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.

Choice C: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.

Choice D: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.

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Correct Answer is ["A","B","E"]

Explanation

Choice C reason: Initiating patient controlled analgesia (PCA. pumps for two clients immediately postoperatively is not a nursing action that can be assigned to the PN. PCA pump is a device that allows the client to self-administer pain medication through an IV line by pressing a button. PCA pump should be initiated by the nurse after verifying the prescription, setting the parameters, educating the client, and ensuring safety and effectiveness. The PN does not have the authority or competency to initiate PCA pump or adjust its settings.

Choice D reason: Starting the second blood transfusion for a client twelve hours following a below knee amputation is not a nursing action that can be assigned to the PN. Blood transfusion is a procedure that delivers donated blood or blood products into the client's bloodstream through an IV line. Blood transfusion should be started by the nurse after verifying the prescription, checking the blood type and compatibility, obtaining informed consent, and monitoring for any adverse reactions. The PN does not have the authority or competency to start blood transfusion or manage its complications.

A. Center attention on positive upbeat music. B. Find outlets for more social interaction. C. Practice using muscle relaxation techniques. D. Think about reasons the episodes occur.

Correct Answer is C

Explanation

Choice A: Centering attention on positive upbeat music is not a specific instruction for the nurse to include, as this is a general coping strategy that may or may not be helpful for this client. This is a distractor choice.

Choice B: Finding outlets for more social interaction is not a relevant instruction for the nurse to include, as this may not address the underlying causes of anxiety or stress for this client. This is another distractor choice.

Choice C: Practicing using muscle relaxation techniques is an appropriate instruction for the nurse to include, as this can help reduce physical tension and promote calmness and relaxation for this client. Therefore, this is the correct choice.

Choice D: Thinking about reasons the episodes occur is not a helpful instruction for the nurse to include, as this can increase rumination and anxiety for this client. This is another distractor choice.

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A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Correct Answer is C

Explanation

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)

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Which environmental factor is most significant when planning care for a client with osteomalacia?

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

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