A nurse is caring for a postoperative client who has an indwelling urinary catheter. Which of the following actions should the nurse take when removing the catheter?

Rapidly deflate the balloon before removing the tubing.

Place the client in the dorsal recumbent position,

Reinsert the catheter if the client does not void within 1 hr.

Obtain a sterile urine specimen after catheter removal.

Answer and Explanation

The Correct Answer is B

A) Rapidly deflate the balloon before removing the tubing:
Rapidly deflating the balloon is not recommended. The balloon should be deflated slowly to ensure complete deflation and prevent trauma to the urethra during removal.

B) Place the client in the dorsal recumbent position:
Placing the client in the dorsal recumbent position (lying on the back with knees bent and feet flat) is appropriate. This position allows for easier access to the catheter and ensures client comfort during the removal process.

C) Reinsert the catheter if the client does not void within 1 hr:
Reinserting the catheter after only 1 hour is premature. It is generally advised to monitor the client for up to 6-8 hours for spontaneous voiding before considering reinsertion. The client should be encouraged to drink fluids and attempts to void should be documented.

D) Obtain a sterile urine specimen after catheter removal:
Obtaining a sterile urine specimen immediately after catheter removal is not necessary. If a urine sample is required, it should be collected before the catheter is removed to ensure sterility

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Correct Answer is B

Explanation

A. Fever
Fever is a common sign of infection, but it may not be the earliest indicator of peritonitis in peritoneal dialysis. It often appears after other more specific symptoms, like changes in the dialysis effluent.
B. Cloudy effluent
Cloudy effluent is the earliest and most specific sign of peritonitis in clients undergoing peritoneal dialysis. It indicates the presence of white blood cells and bacteria, suggesting an infection in the peritoneal cavity.
C. Increased heart rate
An increased heart rate can occur with infection or pain, but it is not specific to peritonitis and may arise later. It is a less direct indicator compared to changes in the dialysis fluid.
D. Generalized abdominal pain
Abdominal pain is a significant symptom but typically follows the early sign of cloudy effluent. It indicates inflammation and irritation in the peritoneal cavity, often accompanying infection progression.

A. Decreased responsiveness of airways to allergens B. Suppressed bronchiolar inflammatory response C. Acute loss of alveolar elasticity D. Inability to exhale retained carbon dioxide

Correct Answer is D

Explanation

A) Decreased responsiveness of airways to allergens:
Asthma is characterized by an increased responsiveness of the airways to various triggers, including allergens, rather than a decreased responsiveness. This heightened sensitivity leads to bronchoconstriction and inflammation, contributing to the symptoms of an asthma attack.

B) Suppressed bronchiolar inflammatory response:
During an asthma attack, there is an exaggerated bronchiolar inflammatory response rather than suppression. Inflammatory mediators cause swelling, mucus production, and constriction of the airways, making it difficult for the client to breathe.

C) Acute loss of alveolar elasticity:
The loss of alveolar elasticity is more characteristic of conditions like emphysema rather than asthma. Asthma primarily involves the airways rather than the alveoli, with symptoms resulting from bronchoconstriction and inflammation rather than loss of elasticity.

D) Inability to exhale retained carbon dioxide:
During an acute asthma attack, bronchoconstriction and airway inflammation lead to air trapping and difficulty in exhaling. This results in the retention of carbon dioxide and subsequent respiratory distress. The inability to exhale effectively exacerbates symptoms, making it a key contributing factor to the manifestations of an asthma attack.

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A nurse is caring for a postoperative client who has an indwelling urinary catheter. Which of the following actions should the nurse take when removing the catheter?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?

Correct Answer is B

Explanation

A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?

Correct Answer is D

Explanation

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