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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypothyroidism is not directly related to obstructive sleep apnea. While sleep apnea can have various systemic effects, hypothyroidism is not a common complication associated with it.
B. Obstructive sleep apnea is strongly associated with an increased risk of hypertension. The repeated episodes of oxygen desaturation and arousal during sleep can contribute to increased blood pressure and cardiovascular strain.
C. Peptic ulcer disease is not a known complication of obstructive sleep apnea. It is generally associated with factors like H. pylori infection, NSAID use, and stress rather than sleep apnea.
D. Fibromyalgia is a chronic pain syndrome and is not typically associated with obstructive sleep apnea. Sleep apnea can exacerbate fatigue and sleep disturbances but does not directly cause fibromyalgia.
Correct Answer is A
Explanation
A. The first priority is to notify the information services department to address the technical issue with the computer system. This ensures that the problem is being handled and allows the nurse to focus on immediate patient care needs.
B. Printing the EMR from the backup server is not possible until the issue with the computer system is resolved. Immediate reporting to IT is necessary to address the technical problem first.
C. Identifying information as a late entry is premature and not the immediate priority. Ensuring the functionality of the electronic system is crucial before making manual records.
D. Waiting for the system to reboot does not address the immediate need for technical support and may delay patient care.
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