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) Place the client on a low-carbohydrate diet:
A low-carbohydrate diet is not appropriate for a client with full-thickness burns, as their nutritional needs are significantly increased due to the high metabolic demands of wound healing. A high-calorie, high-protein diet is usually recommended to support recovery and manage the increased energy expenditure associated with burn injuries.

B) Monitor the client's calorie intake daily:
Daily monitoring of calorie intake is crucial for clients with significant burn injuries. Burns increase metabolic demands, and the client’s nutritional needs must be closely tracked to ensure adequate caloric and protein intake, which is essential for wound healing and overall recovery. Regular monitoring helps adjust dietary needs as required.

C) Place the client on strict bed rest:
Strict bed rest is not indicated for clients with burns, as mobility and physical therapy are important for maintaining muscle strength and preventing complications like contractures. While rest is important, a balanced approach involving gradual mobilization is preferred to support functional recovery.

D) Weigh the client once per week:
Weekly weighing may not be frequent enough for clients with burn injuries, as their weight can fluctuate significantly due to changes in fluid status and nutritional needs. More frequent monitoring is necessary to ensure that the client is receiving adequate nutrition and to assess their overall progress.

A. Confirm that the client's bladder is empty. B. Indicate the risk for autonomic dysreflexia in the client's medical record. C. Place the client in an upright sitting position. D. Administer an antihypertensive medication intravenously.

Correct Answer is C,A,D,B

Explanation

The sequence of steps the nurse should take when caring for a client who has a spinal cord injury and has developed autonomic dysreflexia is as follows:

C. Place the client in an upright sitting position. This helps to lower blood pressure by promoting venous return.

A. Confirm that the client’s bladder is empty. A distended bladder is a common cause of autonomic dysreflexia.

D. Administer an antihypertensive medication intravenously. If the previous interventions do not alleviate the symptoms, medication may be needed to lower the client’s blood pressure.

B. Indicate the risk for autonomic dysreflexia in the client’s medical record. This is important for ongoing care and future healthcare providers.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a full-thickness burn injury covering 15% of their body. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is C,A,D,B

Explanation

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