The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse’s action?
The patient will not interrupt the procedure by asking to go to the bathroom.
To check the patency after abdominal surgery.
Anesthetics can decrease bladder contractility and cause urinary retention.
The patient may void uncontrollably during the procedure.
The Correct Answer is C
Choice A reason: Preventing bathroom interruptions is not the primary rationale. While convenient, indwelling catheters are used for clinical reasons like monitoring or preventing complications. This rationale overlooks the physiological effects of surgery and anesthesia, which are more critical for catheter use in abdominal procedures.
Choice B reason: Checking patency post-surgery is not the primary reason for intraoperative catheter placement. While catheters monitor urine output, the main goal is to manage bladder function during and immediately after surgery, when anesthesia and surgical manipulation increase retention risks, not just patency.
Choice C reason: Anesthetics, especially general or spinal, reduce detrusor muscle contractility, impairing bladder emptying. This increases urinary retention risk during and post-surgery. An indwelling catheter ensures continuous drainage, preventing bladder overdistention, discomfort, or complications like urinary tract infections or bladder injury.
Choice D reason: Uncontrolled voiding during surgery is unlikely under anesthesia, which suppresses bladder reflexes. While catheters prevent intraoperative bladder filling, the primary concern is retention from anesthetic effects, not involuntary voiding, making this rationale less accurate for catheter use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Limiting activity can worsen constipation by reducing bowel motility. Physical activity stimulates peristalsis via abdominal muscle movement and increased blood flow, so advising reduced activity is counterproductive and not recommended for managing constipation.
Choice B reason: While hydration is important, four to five glasses of water daily may be insufficient for older adults, who often need 6-8 glasses (1.5-2 liters) to soften stool and promote bowel movements. This instruction is suboptimal compared to dietary fiber.
Choice C reason: Raw vegetables are high in insoluble fiber, which adds bulk to stool and stimulates peristalsis, easing constipation. This dietary change directly addresses the issue by promoting regular bowel movements, making it a key teaching point for older adults.
Choice D reason: Bearing down hard (Valsalva maneuver) can strain pelvic muscles and increase risks like hemorrhoids or cardiovascular stress, especially in older adults. Gentle defecation with proper positioning is safer, making this instruction inappropriate.
Correct Answer is B
Explanation
Choice A reason: Irrigating an NG tube requires sterile technique and assessment of patency, which are beyond the UAP’s scope. This task involves clinical judgment to avoid complications like aspiration, making it inappropriate for delegation.
Choice B reason: Assisting a client to the bathroom post-enema is within the UAP’s scope, involving mobility support and safety. This task does not require clinical judgment beyond ensuring the client’s stability, making it appropriate for delegation.
Choice C reason: Digital removal of stool is an invasive procedure requiring assessment for complications like vagal stimulation or rectal trauma. It is outside the UAP’s scope, as it demands nursing judgment and skill.
Choice D reason: Checking tube feeding aspirate pH and auscultating bowel sounds involve clinical assessment to confirm tube placement and gastrointestinal function. These tasks require nursing expertise and cannot be delegated to a UAP.
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