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 will have a leg bag to collect the urine."
"You will feel pressure when I inflate the catheter balloon."
"You cannot drink fluids for 4 hours after the procedure."
"You will need to urinate before the procedure."
The Correct Answer is D
Choice A Reason:
Choice B Reason:
Inflating a catheter balloon is typically not part of intermittent catheterization, as it is more commonly associated with indwelling catheters.
Choice C Reason:
There is no need for the client to restrict fluid intake before or after intermittent catheterization. In fact, adequate hydration is generally encouraged.
Choice D Reason:
Intermittent catheterization involves inserting a catheter into the bladder to empty it completely, typically to measure residual urine. Before performing intermittent catheterization, it's essential for the client to try to urinate naturally to ensure that the bladder is as empty as possible. This step helps to provide accurate measurements of residual urine and reduces the risk of complications. Therefore, the nurse should include this information in the teaching to ensure the client understands the procedure's proper preparation. While the use of a leg bag to collect urine may be part of the overall management plan, it is not specific to the teaching about preparing for intermittent catheterization.Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Positioning the knot of the rope at the top of the pulley is incorrect. The knot should be placed at the foot of the bed to ensure proper traction.
Choice B Reason:
Removing the weights for 20 minutes without a healthcare provider's order is not appropriate. If the client experiences severe pain, the nurse should assess the client, evaluate the traction system, and notify the healthcare provider if necessary.
Choice C Reason:
Applying 6.8 kg (15 lb) of weight for use in traction is not the standard practice. The amount of weight used in Buck's traction varies depending on the healthcare provider's orders and the client's specific condition. The nurse should follow the healthcare provider's orders regarding the amount of weight to apply.
Choice D Reason:
Compare bilateral pedal pulses. When caring for a client with Buck's traction, it is essential to regularly assess the circulation to the extremity in traction. Comparing bilateral pedal pulses helps the nurse determine if there are any circulation issues in the affected leg. If the client's circulation is compromised, it can lead to complications such as deep vein thrombosis (DVT) or compartment syndrome.
Correct Answer is D
Explanation
Choice A Reason:
Time-critical medications should generally be given within a specific time frame, usually 30 minutes before or after the scheduled time. Waiting for 60 minutes may lead to suboptimal therapeutic effects or potential complications.
Choice B Reason:
Documentation should occur after medication administration to ensure accuracy. Administering the medication should be confirmed before recording it in the patient's chart.
Choice C Reason:
Correct identification of the patient is crucial to ensure that the medication is given to the right person. Using at least two patient identifiers (e.g., name and date of birth) is a common practice to enhance accuracy.
Choice D Reason:
This is a fundamental safety measure in medication administration. The nurse should check the medication against the medication administration record three times: when removing it from storage, when preparing it, and before administering it to the patient. This helps prevent medication errors.
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