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
Explanation
Rationale:
A. Serum ammonia: In advanced liver disease, the liver's ability to detoxify ammonia is impaired. Ammonia can accumulate in the bloodstream, leading to hepatic encephalopathy, which can cause confusion, lethargy, or even coma. Monitoring serum ammonia levels is essential.
B. Phosphate level: Phosphate levels are not a primary concern in advanced liver disease. Although abnormalities in electrolyte balance can occur, phosphate levels are not directly impacted by liver function in the same way as ammonia or other liver-related markers.
C. Serum troponin: Serum troponin is primarily used to assess for myocardial injury, such as in the case of a heart attack. It is not a relevant marker for liver disease. While cardiac complications can occur in liver disease, troponin levels are not a priority.
D. Glucose level: While glucose metabolism can be affected by liver disease due to impaired glycogen storage and gluconeogenesis, monitoring serum ammonia is more critical in advanced liver disease for assessing hepatic encephalopathy.
Correct Answer is C
Explanation
Rationale:
A. Flumazenil: Flumazenil is used to reverse the effects of benzodiazepines, not opioids like morphine. It would not be effective in this situation since the client is experiencing respiratory depression due to morphine use.
B. Diphenhydramine: Diphenhydramine is an antihistamine, and while it may help with symptoms like itching, it does not reverse respiratory depression caused by opioids. It is not appropriate for this scenario.
C. Naloxone: Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, including respiratory depression. It is the appropriate medication to administer in this situation to quickly reverse the respiratory depression caused by morphine.
D. Calcium gluconate: Calcium gluconate is used to treat calcium channel blocker overdose or certain types of hyperkalemia, but it is not effective for reversing respiratory depression caused by opioids.
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