The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

Power flush with 60 mL to remove mucous obstructions.

Slowly irrigate catheter with saline using an infusion pump.

Clamp the catheter for 30 minutes prior to irrigating.

Use a sterile syringe to irrigate with 20 mL normal saline.

Answer and Explanation

The Correct Answer is B

A. Power flushing with 60 mL might be too forceful and could potentially damage the bladder or catheter. It is important to use a gentle approach to avoid complications.
B. Slowly irrigating the catheter with saline using an infusion pump is appropriate for gently clearing the clots and sediment while maintaining a controlled flow rate. This method is effective in managing obstructions and maintaining catheter patency.
C. Clamping the catheter before irrigation is not recommended as it could lead to increased bladder pressure and discomfort. The goal is to maintain urine flow and prevent complications from clots.
D. Using a sterile syringe to irrigate with 20 mL normal saline may not be sufficient to clear larger clots and sediment. A controlled, slower irrigation method using an infusion pump is generally preferred.

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Correct Answer is C

Explanation

A. While consulting the palliative care team is appropriate for end-of-life care, it is essential first to clarify the client's understanding and wishes regarding "heroic measures" to ensure her preferences are fully understood and respected.
B. Setting up a family conference is important for discussing the client’s wishes with her loved ones, but this should occur after the nurse understands the client's specific desires.
C. The nurse should first discuss with the client what she means by "heroic measures" to ensure that her wishes are clearly understood. This conversation is essential to ensure that any subsequent actions, such as obtaining a DNR order, align with the client’s specific wishes.
D. A DNR prescription is an important step in respecting the client's wishes, but it should only be obtained after confirming exactly what the client means by "heroic measures" and ensuring that she fully understands the implications of a DNR order.

A. The technique is intended to maintain straight spinal alignment. B. Working together can decrease the risk of back injury to the nurses. C. Using two or three people increases client safety. D. Turning instead of pulling reduces the likelihood of skin damage.

Correct Answer is A

Explanation

A. The log rolling technique is specifically intended to maintain straight spinal alignment, which is essential for preventing further injury or complications, particularly for patients with spinal injuries or undergoing post-surgical care. Proper spinal alignment is crucial during the turning process.
B. While working together can help decrease the risk of back injury for nurses, the primary purpose of the log rolling technique is to ensure the client’s spinal alignment.
C. Although using multiple people can enhance safety during the turning process, the main goal of the log rolling technique is to maintain spinal alignment rather than just increasing client safety.
D. Turning instead of pulling helps to reduce skin damage, but the primary reason for using the log rolling technique is to keep the spine aligned, not solely to address skin integrity.

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The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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