Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

Previous history of urinary tract infections.

Client's ability to increase fluid intake.

Client allergies to antiseptic solutions.

Color, clarity, and odor of urine.

Answer and Explanation

The Correct Answer is C

A. While a history of urinary tract infections is important to know for overall assessment and planning of care, it may not directly affect the decision to insert a urinary catheter unless there are specific concerns related to infection prevention.

B. The client's ability to increase fluid intake may be relevant to their overall hydration status and urinary function but is not directly related to the insertion of an indwelling urinary catheter.

C. This is the most important information to obtain because the nurse needs to ensure that the client does not have any allergies to antiseptic solutions that may be used during the catheter insertion procedure to prevent infection.

D. While the color, clarity, and odor of urine are important indicators of urinary health, they are not the most critical information to obtain prior to catheter insertion. However, assessing urine characteristics is important for ongoing monitoring of urinary function and potential
complications post-insertion.

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Correct Answer is B

Explanation

A. While scheduling a client and family conference may be necessary to discuss the plan of care, the immediate concern is to determine the type of advance directive the client has and whether it includes preferences regarding resuscitation.
B. This is the most appropriate action because it addresses the family member's concern and ensures that the client's wishes regarding resuscitation are understood and followed.
C. While checking for a DNR bracelet is important, it does not address the family member's question about why the code was called despite the client having a living will.
D. This statement is incorrect. Living wills can guide decision-making regarding end-of-life care, including resuscitation, depending on the legal requirements and documentation in place.

A. Acetaminophen 350 mg PO every 6 hours for temperature greater than 101° F (38.3°C) B. Place the client on a cardiorespiratory monitor C. Start oxygen 3 L/minute via nasal cannula D. Chest x ray E. Run 0.99% sodium chloride IV infusion at 150 ml/hour F. Start a peripheral IV G. Sputum culture

Correct Answer is ["B","C"]

Explanation

A. Acetaminophen 350 mg PO every 6 hours for temperature greater than 101°F (38.3°C): While controlling fever is important, it is not as urgent as ensuring adequate oxygenation and
monitoring of vital signs. Fever can be managed once the client's respiratory status is stabilized.

B. Place the client on a cardiorespiratory monitor

The correct answer is B. Placing the client on a cardiorespiratory monitor is crucial to continuously monitor vital signs, including heart rate, respiratory rate, oxygen saturation, and cardiac rhythm. Given the client's reported difficulty breathing, this order takes priority to assess the severity of respiratory distress and ensure timely intervention if needed.

C. Start oxygen 3 L/minute via nasal cannula

The correct answer is C. Initiating oxygen therapy is essential for improving oxygenation and respiratory function, especially in a patient with reported difficulty breathing. Administering oxygen can help alleviate hypoxemia and reduce the workload on the respiratory system. This intervention takes precedence in addressing the client's acute respiratory symptoms.
D. Chest x-ray: A chest x-ray is important for further evaluation of the client's respiratory status, but it is not as immediate as placing the client on a cardiorespiratory monitor and initiating oxygen therapy.
E. Run 0.9% sodium chloride IV infusion at 150 mL/hour: Initiating IV fluids is important, but it is not as urgent as addressing the client's respiratory distress and oxygenation needs.
F. Start a peripheral IV: Starting a peripheral IV is necessary for administering medications and fluids, but it can be done after placing the client on a monitor and starting oxygen therapy.

G. Sputum culture: While obtaining a sputum culture is important for identifying the causative organism of the respiratory infection, it is not as urgent as addressing the client's immediate respiratory distress.
H. NPO: NPO status may be necessary for certain diagnostic tests or procedures, but it does not take priority over addressing the client's respiratory distress and oxygenation needs.

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Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Exhibits Which 2 orders should the nurse complete first?

Correct Answer is ["B","C"]

Explanation

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