A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?

"You cannot drink fluids for 4 hours after the procedure."

"You will need to urinate before the procedure."

"You will feel pressure when I inflate the catheter balloon."

"You will have a leg bag to collect the urine."

Answer and Explanation

The Correct Answer is B

The correct answer is B. "You will need to urinate before the procedure." The rationale for this information is that intermittent catheterization is a method of draining urine from the bladder using a thin, flexible tube called a catheter. It is used to measure residual urine, which is the amount of urine left in the bladder after voiding. Residual urine can indicate problems with bladder function, such as obstruction, infection, or nerve damage .

To measure residual urine, the client should first empty their bladder by urinating normally. Then, the nurse will insert the catheter into the urethra and advance it into the bladder.The nurse will measure the amount of urine that drains out of the catheter and record it as residual urine. The nurse will then remove the catheter and dispose of it .

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

The correct answer is C. Putting soiled dressings in a tied plastic bag before placing them in the trash reduces the risk of exposure to blood-borne pathogens for anyone who handles the trash.

A. Blood pressure B. Mental confusion C. Cold, clammy skin D. Sodium level E. Pain F. Heart Rate G. Serum amylase level H. Respiratory status I. Urine output J. Temperature

Correct Answer is ["A","B","C","F","G","I","J"]

Explanation

A.The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2.This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.

B.The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.

C.The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.

D.The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.

E.While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.

F.The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.

G.The serum amylase level is significantly elevated on both days, with a sharp increase from 498 units/L to 1,058 units/L. This finding indicates potential pancreatitis or pancreatic injury, which can lead to serious complications. Given the clinical picture of worsening abdominal pain and elevated lipase (which also increased to 1,283 units/L), it is crucial to report this finding to the provider immediately.

H.The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.

I.The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.

J.The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.

These findings indicate that the client may have severe acute pancreatitis, which can lead to systemic complications such as hypovolemia, shock, hypocalcemia, respiratory failure, and multiorgan failure.

View Question and Answer

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

A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about home infection prevention with a client who is HIV positive. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is assisting in the care of a newly admitted client. Exhibits Which of the following findings should the nurse report immediately to the provider? Select all that apply.

Correct Answer is ["A","B","C","F","G","I","J"]

Explanation

A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the highest in potassium?

A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

A nurse is preparing to give a change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report?

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in theteaching?

A nurse is evaluating the laboratory values of a client who is receiving epoetin alfa. Which of the following findings indicates a therapeutic response to the medication?

A nurse is reinforcing discharge teaching with a client who has angina and a prescription for sublingual nitroglycerin tablets. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?