In assessing a client with an indwelling urinary catheter following the provision of care by an unlicensed assistive personnel (UAP), the practical nurse (PN) observes that the catheter drainage bag, which is half- full, is attached to the side rail and the tubing is looped on the bed.
Which action should the PN implement?
Apply gloves and empty the drainage bag
Remove the looped tubing from the bed
Measure the urinary output in the bag
Attach the drainage bag to the bed frame
The Correct Answer is D
The correct answer is choice d. Attach the drainage bag to the bed frame.
Choice A rationale:
Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full.
Choice B rationale:
Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag.
Choice C rationale:
Measuring the urinary output in the bag is a routine task but does not correct the improper placement of the drainage bag.
Choice D rationale:
Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Monitoring blood pressure is a general health assessment measure and may not directly contribute to pain relief in a client with migraine headaches. While it's essential to manage blood pressure as part of overall health, this choice does not address the client's specific request for pain relief.
Choice B rationale:
Taking a few days off work may provide some relief from external stressors, but it is not a reliable intervention for migraine pain relief. Migraine management typically involves strategies that directly target headache symptoms.
Choice C rationale:
Learning muscle relaxation techniques can be helpful in managing migraine headaches. Relaxation techniques, such as progressive muscle relaxation, can reduce muscle tension and help alleviate headache symptoms. However, it may not be the highest-priority intervention.
Choice D rationale:
Lying down in a dark, quiet room is the most appropriate intervention for obtaining pain relief from a migraine headache. This approach minimizes sensory stimuli, reduces external factors that may exacerbate the headache, and promotes relaxation. It is a well-established non-pharmaceutical method for managing migraine pain.
Correct Answer is D
Explanation
The correct answer is d. hypovolemic.
Choice A reason: This is not a good choice. Septic shock is a type of distributive shock that occurs when an infection causes a systemic inflammatory response that leads to vasodilation, hypotension, and organ dysfunction. Septic shock is not the most common type of shock in children, although it can be a serious and life-threatening condition.
Choice B reason: This is not a good choice. Anaphylactic shock is a type of distributive shock that occurs when an allergic reaction causes a severe and rapid hypersensitivity response that leads to bronchoconstriction, angioedema, and hypotension. Anaphylactic shock is not the most common type of shock in children, although it can be a medical emergency that requires immediate treatment.
Choice C reason: This is not a good choice. Distributive shock is a broad category of shock that occurs when there is a loss of vascular tone and blood volume distribution that leads to hypoperfusion and tissue hypoxia. Distributive shock can be caused by various factors, such as sepsis, anaphylaxis, neurogenic injury, or adrenal insufficiency. Distributive shock is not the most common type of shock in children, although it can be a complex and challenging condition to manage.
Choice D reason: This is the correct choice. Hypovolemic shock is the most common type of shock in children. Hypovolemic shock occurs when there is a loss of blood or fluid volume that leads to decreased preload, cardiac output, and blood pressure. Hypovolemic shock can be caused by various factors, such as hemorrhage, dehydration, vomiting, diarrhea, or burns. Hypovolemic shock can be a life-threatening condition that requires prompt fluid resuscitation and correction of the underlying cause.
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