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

Answer and Explanation

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

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Correct Answer is ["A","B","C","D","E","H","I"]

Explanation

Findings that indicate the client has a potential problem:

Chest pain radiating to left arm: Chest pain that radiates to the left arm is a classic symptom of a myocardial infarction (MI). The description of pain (tightness) and its radiation to the left arm are a red flag for an acute cardiac event, which requires immediate intervention.
Pain level of 7 on a scale of 0 to 10: A pain level of 7 indicates significant discomfort, and when combined with other symptoms like chest tightness and radiation to the left arm, it further supports the possibility of a myocardial infarction.
Started to feel nauseous after breakfast: Nausea can be an associated symptom of acute myocardial infarction (MI), especially in women, the elderly, and those with diabetes. Its presence, along with chest pain, is concerning.
Diaphoresis: Diaphoresis (excessive sweating) is often associated with myocardial infarction and is a key sign of acute coronary syndrome. This finding, along with chest pain and shortness of breath, suggests an emergent situation.
Tachycardia with irregular heart rate: The client’s heart rate is 110/min and irregular, which can be indicative of arrhythmias commonly seen in acute myocardial infarction. The irregular and tachycardic rhythm should be immediately evaluated to prevent further complications.
+1 pedal pulses: While present, +1 pedal pulses are diminished. This could indicate compromised peripheral circulation, possibly related to overall cardiovascular compromise or underlying peripheral artery disease, which is often co-morbid with the client's existing conditions (hyperlipidemia, hypertension, diabetes).
Skin is cool to touch: Cool skin, especially when accompanied by other signs of poor perfusion like diminished pulses, can indicate reduced peripheral blood flow, which may be a systemic response to decreased cardiac output from a significant cardiac event.

Rationale for Incorrect Findings:

Lungs clear to auscultation: Clear lung sounds suggest no signs of pulmonary edema or other lung issues at the moment, ruling out respiratory causes of the symptoms.
Bowel sounds present in all 4 quadrants: The presence of bowel sounds in all quadrants is normal and suggests that the gastrointestinal system is functioning well.
Capillary refill less than 2 seconds is normal and indicate adequate perfusion, this finding on its own does not require follow up.

A. Pain level B. Urinary output C. Blood pressure D. Respiratory rate E. Echocardiogram results F. Oxygenation saturation G. Heart rate

Correct Answer is ["A","C","F","G"]

Explanation

Rationale:

A. Pain level: The client's pain level decreased from 7/10 to 5/10 after 2 doses of nitroglycerin, which indicates that the treatment is effective in reducing the chest pain associated with myocardial infarction (MI).

B. Urinary output: The client's urinary output (32 mL) is still low compared to intake (500 mL), suggesting potential renal perfusion issues. Urine output should be more closely monitored as it may indicate worsening shock or poor kidney perfusion.

C. Blood pressure: The client's blood pressure has decreased from 176/82 mm Hg to 110/62 mm Hg. A drop in blood pressure, especially after treatment with nitroglycerin and morphine, suggests that the heart's workload is reducing and the condition is stabilizing.

D. Respiratory rate: The respiratory rate has decreased slightly from 24/min to 22/min, but it still remains elevated. This may indicate ongoing respiratory distress or the need for further assessment and stabilization of the respiratory system.

E. Echocardiogram results: The echocardiogram results indicate a myocardial infarction, which means that while the condition is identified, it does not yet suggest improvement. Further monitoring and interventions are required to prevent further damage to the heart muscle.

F. Oxygen saturation: Oxygen saturation improved from 89% on room air to 92% with supplemental oxygen at 2 L/min via nasal cannula. This increase indicates better oxygenation, which is crucial for recovery in a patient with a myocardial infarction.

G. Heart rate: The client's heart rate decreased from 120/min to 100/min. This reduction indicates improvement in the heart's rhythm and better control of tachycardia, which is important for the stabilization of the patient following MI.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","H","I"]

Explanation

The nurse is reviewing the client's medical record. Exhibits The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.

Correct Answer is ["A","C","F","G"]

Explanation

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