The nurse is assessing a patient with a urinary catheter.
Which of the following would be a priority nursing intervention?
Removing the catheter as soon as possible to prevent infection.
Ensuring that the catheter is properly secured to prevent accidental dislodgement.
Encouraging the patient to drink fluids to prevent dehydration.
Administering antibiotics to prevent infection.
Administering antibiotics to prevent infection.
The Correct Answer is A
This is because urinary catheters are a common source of catheter associated urinary tract infections (CAUTIs), which can lead to complications such as pyelonephritis, sepsis, and renal failure. Therefore, the nurse should remove the catheter as soon as possible to reduce the risk of infection and promote normal urinary function.
Choice B is wrong because ensuring that the catheter is properly secured to prevent accidental dislodgement is not a priority intervention for a patient with a urinary catheter.
While this is an important nursing action to prevent trauma and bleeding, it does not address the main complication of catheterization, which is infection.
Choice C is wrong because encouraging the patient to drink fluids to prevent dehydration is not a priority intervention for a patient with a urinary catheter.
While this is a good nursing practice to maintain hydration and renal perfusion, it does not affect the risk of infection associated with catheterization.
Choice D is wrong because administering antibiotics to prevent infection is not a priority intervention for a patient with a urinary catheter.
While this may be indicated for some patients who have signs and symptoms of UTI or who are at high risk of infection, it is not a routine measure for all patients with catheters and may contribute to antibiotic resistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because hemodialysis removes excess fluid and waste products from the blood, but it also removes some electrolytes, such as potassium.
Potassium is important for nerve and muscle function, especially the heart.
If potassium levels are too high or too low, it can cause irregular heartbeat or cardiac arrest.
Choice B is wrong because hypokalemia means low potassium levels, which is unlikely in renal failure unless there is excessive potassium loss from diarrhea, vomiting or diuretics.
Choice C is wrong because hyponatremia means low sodium levels, which can occur in renal failure due to fluid retention, but it is not directly related to hemodialysis.
Choice D is wrong because hypernatremia means high sodium levels, which can occur in renal failure due to reduced urine output, but it is also not directly related to hemodialysis.
Normal ranges for electrolytes are: Potassium: 3.5 to 5.0 mmol/L
Sodium: 135 to 145 mmol/L
Calcium: 8.5 to 10.5 mg/dL
Chloride: 96 to 106 mmol/L
Magnesium: 1.7 to 2.2 mg/dL
Phosphate: 2.5 to 4.5 mg/dL
Bicarbonate: 22 to 29 mmol/L
Correct Answer is B
Explanation
This is because hyperkalemia is a condition where the blood potassium level is too high.
This can cause cardiac arrhythmias, muscle weakness, and paralysis. Therefore, the nurse should administer intravenous insulin and glucose to lower the blood potassium level by shifting it into the cells.
Choice A is wrong because encouraging the patient to consume a high- potassium diet would increase the blood potassium level and worsen the condition.
Choice C is wrong because administering a potassium-sparing diuretic would prevent the excretion of excess potassium and aggravate the hyperkalemia.
Choice D is wrong because encouraging the patient to limit fluid intake is not relevant to the management of hyperkalemia and may cause dehydration.
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