The client asks the nurse "Why is it necessary to secure the indwelling urinary catheter to my thigh?" The nurse's best response would be. "It is Important to prevent:

urinary leakage around the catheter."

fecal matter from entering your bladder."

injury to your urethra."

the catheter from slipping out of your bladder."

Answer and Explanation

The Correct Answer is A

A. Urinary leakage around the catheter: Securing the indwelling urinary catheter to the thigh helps prevent urinary leakage around the catheter site. Catheter movement or dislodgement can lead to leakage of urine around the catheter, which can cause skin irritation, increase the risk of urinary tract infections (UTIs), and compromise hygiene. Securing the catheter to the thigh helps maintain its position and prevents movement that could contribute to leakage.

B. Fecal matter from entering your bladder: While securing the catheter can help maintain proper positioning and prevent movement, its primary purpose is not to prevent fecal matter from entering the bladder. Indwelling urinary catheters are inserted into the bladder through the urethra, and proper catheter placement and hygiene practices are essential for preventing contamination of the urinary tract with fecal matter.

C. Injury to your urethra: Securing the catheter to the thigh does not directly prevent injury to the urethra. Proper insertion technique and appropriate catheter size selection are more critical for preventing urethral injury during catheterization. Securing the catheter primarily aims to maintain its position and prevent movement that could potentially cause discomfort or complications.

D. The catheter from slipping out of your bladder: While securing the catheter can help prevent inadvertent dislodgement, its primary purpose is not to prevent the catheter from slipping out of the bladder. Proper catheter securement techniques, including securing it to the thigh or using catheter stabilization devices, help maintain the catheter's position and minimize movement, reducing the risk of accidental removal.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Use open-ended questions to find out about the sensation: While open-ended questions can help the nurse gather information about the nature and quality of the pain, they may not provide a precise measure of pain intensity. Open-ended questions are valuable for understanding the client's subjective experience of pain, but they may not be as effective as using a pain scale for quantifying pain intensity.

B. Offer the client a pain scale to quantify the current level of pain: This is the most appropriate action for assessing pain intensity. Pain scales, such as the Numeric Rating Scale (NRS) or Visual Analog Scale (VAS), allow clients to indicate their pain intensity on a scale from 0 to 10 or by marking a point along a continuum. Pain scales provide a standardized method for quantifying pain intensity, which helps healthcare providers monitor changes in pain over time and assess the effectiveness of pain management interventions.

C. Question the client about the location of the pain: While identifying the location of pain is important for understanding its source and potential underlying causes, it does not directly assess pain intensity. Location is one aspect of pain assessment but does not provide a complete picture of pain intensity on its own.

D. Ask about what precipitates the pain: Understanding what precipitates or exacerbates pain is important for comprehensive pain assessment, but it focuses more on pain triggers rather than pain intensity. While this information can be valuable for developing a holistic pain management plan, it does not directly assess the current level of pain intensity.

A. draw a straight line through the error with a black ink pen and initial it. B. use a permanent marker to draw a line through the error and write "mistaken entry". C. cover the mistake with correction fluid and skip a line. D. erase the error and write the correct information.

Correct Answer is A

Explanation

A. Draw a straight line through the error with a black ink pen and initial it: This is the correct action to take when making an error while documenting in the client's chart. Drawing a single line through the error with a black ink pen ensures that the original information remains visible for auditing purposes. The nurse should then write the correct information above or adjacent to the error, initial the correction, and include the date and time. This method maintains the integrity of the documentation while clearly indicating that an error was made and corrected.

B. Use a permanent marker to draw a line through the error and write "mistaken entry": Using a permanent marker is not appropriate because it can make the chart difficult to read and may obscure the original information. Additionally, writing "mistaken entry" does not provide sufficient clarification regarding the nature of the error or the correction made.

C. Cover the mistake with correction fluid and skip a line: Using correction fluid to cover the mistake is not recommended because it can make the chart appear altered or tampered with. Skipping a line does not adequately address the error and correction, and it may lead to confusion when reviewing the documentation.

D. Erase the error and write the correct information: Erasures are not recommended in documentation as they can be perceived as altering or tampering with the chart. Additionally, erasing information may not completely remove it from the chart, and it may still be legible under certain lighting conditions or with the use of special equipment.

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The client asks the nurse "Why is it necessary to secure the indwelling urinary catheter to my thigh?" The nurse's best response would be. "It is Important to prevent:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is most appropriate when the nurse assesses the intensity of the client's pain?

Correct Answer is B

Explanation

The nurse makes an error while documenting in the client's chart. The nurse should:

Correct Answer is A

Explanation

When caring for a patient in pain, the most important principle that the nurse must recognize is that:

A client, who is on bedrest after surgery, complains of feeling bloated and having continuous oozing of small amounts of liquid stool. The nurse recognizes this as being symptomatic of which condition?

The nurse is teaching a client who will be collecting a stool sample for a hemoccult test. The nurse determines that teaching has been effective when the client states:

A nurse is caring for a client being treated for a fluid volume excess. Which clinical finding validates the client's fluid status?

Which position would be appropriate for the nurse to perform an abdominal assessment?

The nurse is prioritizing the day's interventions. Which client should be the first to be taught about the hazards of straining when having a bowel movement? The:

A client who is under extreme stress will have an increased production of antidiuretic hormone (ADH) and aldosterone. The nurse should expect a decrease in which clinical finding?