The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?

Cleanse the catheter from the meatus outward using mild soap and warm water.

Use the same cleansing cloth for cleaning of the perineal area and the catheter tubing.

Use chlorhexidine gluconate (CHG) to cleanse the perineal area

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. When performing hygiene care for a client with an indwelling catheter, the nurse should plan to cleanse the catheter from the meatus outward using mild soap and warm water. This helps to prevent infection and ensure proper hygiene. Using the same cleansing cloth for cleaning the perineal area and catheter tubing (choice B) is not recommended as it can cause contamination and increase the risk of infection. The use of chlorhexidine gluconate (CHG) to cleanse the perineal area (choice C) is not necessary for routine catheter care and should only be used for specific indications such as preventing infection during surgery. Therefore, the nurse should always follow proper hygiene protocols and cleanse the catheter from the meatus outward using mild soap and warm water when caring for a client with an indwelling catheter.

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Correct Answer is C

Explanation

The correct answer is choice C. "I will need palliative care to assist with treating my symptoms so that I can have quality of life across the span of my illness." Palliative care aims to improve the quality of life of patients and their families facing life-threatening illnesses. The goal of palliative care is to provide symptom management, pain relief, and support to patients and families throughout the course of their illness. Hospice care is a type of palliative care for patients with a life expectancy of six months or less, where the focus of care is comfort rather than curative treatment.

A. Recognize this as a normal PVR and document the amount in the patient's chart. B. Recognize this as an abnormal PVR, call the physician, and recommend an external catheter be applied. C. Recognize this as an abnormal PVR, call the physician, and obtain an order for an in-and-out catheterization. D. Recognize this as an abnormal PVR and try to have the client void again in a few hours.

Correct Answer is C

Explanation

A.This option is incorrect because a PVR of 400 mL is significantly higher than normal. Documenting without further intervention could lead to complications if the high residual volume persists.

B.While an external catheter may be beneficial for managing incontinence or monitoring urine output, it does not address the underlying issue of urinary retention. An external catheter would not relieve the retained urine in the bladder.

C.A post-void residual (PVR) of 400 mL is abnormally high, indicating that the bladder is not emptying effectively, which can lead to discomfort, urinary tract infection (UTI), and potential kidney issues if left untreated. An in-and-out catheterization allows for temporary relief by emptying the bladder and can also help prevent bladder distention. Contacting the physician to report the findings and obtain an order is appropriate to manage this condition safely.

D. Encouraging the client to attempt voiding again without intervention may not be effective in reducing the high PVR. This delay could increase the risk of bladder distention and discomfort.

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The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While caring for a female patient with advanced multiple sclerosis, the nurse is discussing the difference between hospice and palliative care. Which statement by the patient indicates understanding of the difference between hospice care and palliative care?

Correct Answer is C

Explanation

A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

Correct Answer is C

Explanation

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