A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply).
Measurement of residual urine after urination
An open perineal wound
Relief of urinary retention
Convenience for the nursing staff or the client's family
routine acquisition of a urine specimen
Correct Answer : A,B,C
A. Measurement of residual urine after urination is an indication of urinary catheterization because it can help diagnose conditions such as neurogenic bladder, bladder outlet obstruction, or urinary retention.
B. An open perineal wound is an indication for urinary catheterization because it can prevent contamination of the wound by urine and facilitate wound healing.
C. Relief of urinary retention is an indication of urinary catheterization because it can prevent complications such as bladder distension, infection, or renal damage.
D. Convenience for the nursing staff or the client's family is not an indication of urinary catheterization because it can increase the risk of catheter-associated urinary tract infection (CAUTI), trauma, or encrustation.
E. routine acquisition of a urine specimen is not an indication for urinary catheterization because it can be obtained by other methods such as clean catch, midstream, or suprapubic aspiration.
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Related Questions
Correct Answer is D
Explanation
A. Dehydration is unlikely to cause blood-tinged urine. Dehydration can lead to concentrated urine, but it typically does not cause blood in the urine.
B. Pernicious anemia is a condition related to a deficiency in vitamin B12, which can lead to a decrease in red blood cell production. However, it is not directly associated with blood in the urine.
C. Bladder infection can cause blood in the urine, but it is more commonly associated with symptoms such as urinary frequency, urgency, and burning during urination. If blood is present, it is usually due to inflammation of the bladder lining.
D. Prostate enlargement, also known as benign prostatic hyperplasia (BPH), can cause blood-tinged urine. The prostate gland surrounds the urethra, and enlargement can lead to irritation and bleeding from the urinary tract.
Correct Answer is B
Explanation
A. The head of the bed should generally be elevated no more than 30° to reduce shear and friction, not 45°.
B. Using a transfer device to lift the client prevents shearing and friction, which helps maintain skin integrity and reduces the risk of pressure ulcers.
C. Massaging bony prominences is not recommended, as it can damage underlying tissue and increase risk of ulcer formation.
D. Cornstarch is not advised because it can create a moist environment that promotes skin breakdown and infection.
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