A nurse is performing a bladder irrigation for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Slowly instill 400 to 500 mL of the prescribed solution.

Clamp the drainage tubing distal to the injection port.

Use a syringe with a 19-gauge needle.

Withdraw the irrigation solution into the syringe.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

During bladder irrigation, the nurse should instill a specific volume of the prescribed irrigation solution into the bladder to facilitate the removal of clots, mucus, or other debris from the urinary catheter and bladder. The recommended volume to instill is usually 400 to 500 mL, which helps to effectively flush out the bladder without overdistending it.

Choice B rationale:

Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.

Choice C rationale:

Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.

Choice D rationale:

Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.

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Correct Answer is A

Explanation

Choosing the best intervention for a client with fever due to infection:

The most appropriate intervention for a client with fever due to infection depends on various factors, including the severity of the fever, the client's age and overall health, and their individual preferences. Let's analyze each option and explain its rationale:

a. Encourage fluid intake of 2,500 mL/day.

Rationale:

Pros:Fever often leads to increased sweating and fluid loss through respiration. Maintaining adequate hydration is crucial to prevent dehydration, which can worsen discomfort and potentially lead to complications like organ dysfunction. Encouraging a fluid intake of 2,500 mL/day is generally recommended for adults with fever, although individual needs may vary based on factors like body size and activity level.
Cons:While hydration is essential, forcing fluids on a client who experiences nausea or vomiting can be counterproductive. Additionally, some clients with certain medical conditions, like heart failure, may require fluid restriction, making this option inappropriate.

b. Maintain the environmental temperature at 16°C to 18°C (60°F to 65°F).

Rationale:

Cons:Excessively cool environments can trigger shivering, which actually increases body heat production and can worsen the fever. Additionally, maintaining such a low room temperature can be uncomfortable for the client and may increase their risk of chills.

c. Immerse the client in cold water.

Rationale:

Cons:Immersing a client in cold water, like a bath, can be a dangerous and counterproductive intervention. The sudden chill can trigger violent shivering, significantly increasing body heat production and potentially causing shock. Moreover, rapid cooling can be uncomfortable and even risky for people with certain health conditions like heart disease.

d. Assist the client to ambulate.

Rationale:

Cons:While ambulation is generally encouraged for healthy clients, it may not be suitable for everyone with a fever. Depending on the severity of the fever and the client's overall condition, ambulation could be tiring and even unsafe. In some cases, rest may be more appropriate to promote comfort and recovery.

Therefore, the most appropriate intervention for a client with fever due to infection is:

a. Encourage fluid intake of 2,500 mL/day.

Remember:

Individualize care based on the client's specific needs and preferences.
Monitor the client's response to interventions and adjust as needed.
Consult with the healthcare provider for guidance on managing the fever and addressing any underlying infection.

A. Encourage the client to ambulate. B. Give the client a cold sponge bath. C. Administer antipyretics as prescribed. D. Provide a cooling fan.

Correct Answer is C

Explanation

Choice A rationale:

Encouraging the client to ambulate is not appropriate when the client has a high fever of 40°C (104°F). Ambulation requires physical exertion and can potentially worsen the client's condition, especially when they are already experiencing discomfort due to the fever.

Choice B rationale:

Giving the client a cold sponge bath might seem like a logical approach to reduce fever; however, it is not the most effective and safest method. Cold water can cause vasoconstriction and shivering, potentially increasing the body's metabolic demands and raising the temperature further. Additionally, sudden temperature changes can be uncomfortable and may not provide sustained fever reduction.

Choice C rationale:

Administering antipyretics as prescribed is the correct choice. Antipyretic medications, such as acetaminophen or ibuprofen, work to lower fever by acting on the hypothalamus, the body's temperature-regulating center. By reducing fever, the body's metabolic rate and oxygen consumption are decreased, which can help prevent complications associated with high fever, such as dehydration and discomfort.

Choice D rationale:

Providing a cooling fan can offer some comfort, but it might not be sufficient to effectively lower the client's high fever. Fans primarily work by promoting evaporative cooling, which may not be efficient when the body temperature is significantly elevated. Additionally, relying solely on a cooling fan might delay the necessary intervention of administering antipyretic medication.

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A nurse is performing a bladder irrigation for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

Choosing the best intervention for a client with fever due to infection:

A nurse is caring for a client who has a temperature of 40°C (104°F). Which of the following interventions should the nurse take?

Correct Answer is C

Explanation

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