A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?
Urge incontinence
Weight gain
Rectal distention
Dribbling of urine
The Correct Answer is D
A. Urge incontinence may occur but is not necessarily an indicator for immediate catheterization in a paraplegic patient, as they may lack bladder control.
B. Weight gain is unrelated to the need for catheterization and may indicate other issues like fluid retention.
C. Rectal distention relates to bowel function, not bladder function, and does not indicate the need for catheterization.
D. Dribbling of urine can suggest bladder overfilling and is an indication that the bladder needs emptying through catheterization to prevent urinary retention complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"D"},"E":{"answers":"A"}}
Explanation
Platelet count: Low platelets (135,000/mm³) increase bleeding risk as they are essential for clot formation.
Hemoglobin: A hemoglobin level within the low normal range could increase the risk of hypoxemia, particularly in the perioperative period when oxygen demand may be higher.
INR: Elevated INR (1.5) indicates increased bleeding risk due to prolonged clotting time.
Atrial fibrillation: Increases the risk of DVT due to irregular heart rhythms, which can lead to blood pooling and clot formation.
RBC count: A low RBC count contributes to the risk of hypoxemia as there are fewer red blood cells available to transport oxygen.
Correct Answer is B
Explanation
A. Ambulating soon after surgery is encouraged to promote circulation and decrease the risk of VTE.
B. Massaging the legs is unsafe, as it can dislodge any existing clot, potentially leading to a pulmonary embolism.
C. Elevating the feet helps improve venous return and is a safe practice to reduce VTE risk.
D. Flexing the ankles is part of exercises that help promote blood flow and reduce clot formation risk.
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