A nurse is planning to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse plan to take?
Raise the head of the bed to 45° prior to insertion.
Secure the catheter to the client's inner thigh.
Attach the bag to the rail of the bed.
Collect a urine specimen from the drainage bag 1 hr after insertion
The Correct Answer is B
Rationale:
A. Raise the head of the bed to 45° prior to insertion: The head of the bed should not be raised to 45° prior to catheter insertion. The client should be in a comfortable, supine position with the legs slightly apart to facilitate proper catheter insertion.
B. Secure the catheter to the client's inner thigh: Securing the catheter to the client's inner thigh helps prevent tension on the catheter and reduces the risk of discomfort or accidental dislodgement. This is a standard practice for catheter care.
C. Attach the bag to the rail of the bed: The urinary drainage bag should never be attached to the bed rail, as it could lead to the backflow of urine into the bladder, increasing the risk of infection. The bag should be placed lower than the bladder and secured to the bed frame.
D. Collect a urine specimen from the drainage bag 1 hr after insertion: Urine specimens should not be collected from the drainage bag because the urine in the bag may be contaminated. A clean-catch specimen or a specimen collected directly from the catheter should be used for accurate testing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}
Explanation
Rationale:
- Hold the client's metoprolol: The client's heart rate is 112/min and irregular, and the ECG shows atrial fibrillation. Metoprolol helps manage heart rate. Holding it would worsen the tachycardia and the symptoms of heart failure. The blood pressure is also still elevated (146/82 mm Hg), indicating that the metoprolol is still needed.
- Increase the dosage of furosemide: The client’s weight has increased by 1.8 kg (4 lbs) within 24 hours, indicating fluid retention, which is a common symptom of heart failure. Increasing the dosage of furosemide will help manage fluid overload by promoting diuresis and reducing symptoms such as edema and shortness of breath.
- Decrease the client's oxygen to 1 L/min via nasal cannula: The client's oxygen saturation has decreased from 93% to 90% while on 2 L/min of oxygen. This indicates worsening oxygenation or increased oxygen demand due to fluid overload. The client needs continued or even increased oxygen.
- Restrict the client's fluid intake to 2 L per day: The client is showing signs of fluid overload (weight gain, decreased SpO2, elevated BNP). Fluid restriction is a necessary intervention in heart failure to manage fluid balance and prevent further accumulation of fluid
- Weigh the client daily: Daily weight monitoring is crucial in clients with heart failure to detect fluid retention early. A significant increase in weight can indicate worsening heart failure or fluid overload, which requires immediate intervention.
- Begin a 24-hr urine collection for the client: A 24-hour urine collection is used for assessing kidney function, electrolytes, and proteinuria. There is no immediate indication for this test in the current clinical scenario.
Correct Answer is A
Explanation
Rationale:
A. "I need to check my pulse rate every day for a full minute." After pacemaker insertion, it is important for the client to monitor their pulse to ensure the pacemaker is working properly. The pulse should be checked daily for a full minute to detect any irregularities in heart rate.
B. "I need to maintain pressure over the pacemaker site with an elastic bandage." Pressure should not be applied over the pacemaker site, as it could interfere with proper healing or dislodge the device. The pacemaker site should be kept clean and free from excessive pressure.
C. "When a microwave oven is in use, I need to stay out of the room." Modern pacemakers are shielded from electromagnetic interference, such as from microwave ovens. The client can use a microwave without leaving the room, unless otherwise instructed by their healthcare provider.
D. "The pacemaker will deliver a shock if I develop a dysrhythmia." Most permanent pacemakers do not deliver shocks; instead, they provide electrical impulses to regulate the heart's rhythm. A defibrillator, not a pacemaker, delivers shocks for life-threatening dysrhythmias.
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