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
Explanation
A. Wrapping the residual limb in a figure-eight configuration provides compression and support, shaping the limb for prosthesis fitting, and promoting proper circulation.
B. Wrapping in a proximal-to-distal direction can restrict blood flow and does not provide the appropriate support needed for prosthetic shaping.
C. The bandage should be rewrapped more frequently than once a day to maintain compression and limb shape.
D. Securing the bandage at the lowest joint is inadequate as it may allow loosening and improper shaping of the residual limb.
Correct Answer is ["1733"]
Explanation
To calculate the infusion rate for the first 8 hours, you would take the total volume prescribed for the first 24 hours and divide it by 3, since 8 hours is one-third of 24 hours. So, 5,200 mL divided by 3 equals approximately 1,733.33 mL. Rounding this to the nearest whole number, the nurse should set the pump to infuse at a rate of 1,733 mL per hour for the first 8 hours.
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