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 D

A. Power flushing with 60 mL of solution can create excessive pressure in the bladder, increasing the risk of trauma or forcing bacteria into the urinary tract. Gentle irrigation is preferred to safely remove clots and sediment without causing injury.

B. Using an infusion pump to slowly irrigate the catheter may not allow proper control of pressure and volume, which can damage the bladder mucosa. Manual irrigation allows the nurse to assess resistance and stop if obstruction or discomfort occurs.

C. Clamping the catheter for 30 minutes before irrigation can increase bladder pressure and cause discomfort or potential reflux of urine into the kidneys. Routine pre-irrigation clamping is not recommended unless specifically ordered for retention management.

D. Using a sterile syringe with 20 mL of normal saline allows controlled, gentle irrigation to remove clots and sediment. Sterile technique reduces the risk of introducing pathogens, and the small volume minimizes bladder trauma while effectively clearing the catheter.

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Correct Answer is C

Explanation

A. Journaling can be helpful for self-reflection but does not provide the interactive, practice-oriented learning needed to improve communication skills in challenging situations.
B. Return demonstration is typically used for teaching physical tasks and skills, not for communication or interpersonal interactions.
C. Role-playing is the best instructional strategy in this scenario. It allows nursing staff to practice handling difficult conversations in a controlled environment, receive feedback, and build confidence in managing real-life situations involving angry family members.
D. Analogies can be useful for explaining concepts, but they do not provide the experiential learning needed to effectively respond to anger.

A. Incorporate verbal analogies. B. Offer positive reinforcement. C. Provide physical demonstrations. D. Use simulation activities.

Correct Answer is D

Explanation

A. Verbal analogies can help in understanding concepts, but they may not fully engage young adults in active problem-solving.
B. Positive reinforcement is important for motivation, but it does not directly involve the clients in problem-solving strategies.
C. Physical demonstrations are effective for teaching skills, but they may not be the most engaging method for problem-solving.
D. Simulation activities are highly effective in engaging young adults in problem-solving strategies. These activities allow participants to actively apply their knowledge and think critically in a controlled environment, making them a valuable tool for teaching problem-solving.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is D

Explanation

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