A nurse is offering teaching to a caregiver about urinary system complications that occur as a result of spinal cord injury. Which of the following will the nurse include in teaching?
A Drain the bladder with a clean intermittent catheter every hour
B Decrease fluid intake
C Observe the urine for a foul odor
D Keep an indwelling catheter in place at all times
The Correct Answer is A
Choice A Rationale: The nurse will include instructions on draining the bladder with a clean intermittent catheter at appropriate intervals to prevent urinary retention and complications. This should be done every 3 to 6 hours, depending on the amount of fluid intake and output.
Choice B Rationale: Decreasing fluid intake is not typically recommended for individuals with spinal cord injuries, as adequate hydration is important.
Choice C Rationale: Observing the urine for a foul odor is relevant to monitor for urinary tract infections, but it is not a preventive measure.
Choice D Rationale: Keeping an indwelling catheter in place at all times is not typically recommended due to the increased risk of urinary tract infections and other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.
Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.
Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.
Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.
Correct Answer is B
Explanation
Choice A Rationale: Notifying the physician may be necessary if troubleshooting the issue does not resolve the problem, but it is not the initial step.
Choice B Rationale: The nurse should first check the tubing of the indwelling urinary catheter for any kinks, twists, or obstructions that might prevent the urine flow. This is a simple and non-invasive intervention that can resolve the problem quickly and easily.
Choice C Rationale: Removing the indwelling catheter is not advisable without proper assessment and intervention, as it can lead to complications.
Choice D Rationale: Replacing the indwelling catheter is not the first step and should only be done if the problem cannot be resolved through assessment and interventions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.