The practical nurse (PN) is documenting the insertion of a urinary catheter for a female client with urinary retention. What information should the PN include during the electronic documentation of the procedure? Select all that apply.

Client positioning during procedure.

Amount of lubricant used.

Size of urinary catheter.

Appearance of urine obtained.

Amount of urine obtained.

Answer and Explanation

Correct Answer : A,C,D

A. Client positioning during the procedure should be documented to ensure that the procedure was performed correctly and that the client was appropriately positioned for catheter insertion.
B. The amount of lubricant used is not a standard detail for documenting catheter insertion. Documentation focuses on the procedure's outcomes and specific technical details rather than quantities of materials used.
C. The size of the urinary catheter should be documented as it is a critical detail for future reference and to ensure that the catheter was appropriate for the client’s needs.
D. The appearance of the urine obtained should be documented as it provides important information about the client’s urinary status and can indicate potential issues like infection or hematuria.
E. While the amount of urine obtained might be relevant for assessing urinary retention, it is not a standard part of the initial documentation for catheter insertion unless there was a significant volume change or specific concern.

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Correct Answer is A

Explanation

A. Evisceration is the protrusion of internal organs, such as the bowel, through a wound that has reopened. The observation of bowel on the skin indicates this serious complication.
B. Hemorrhage refers to excessive bleeding, which would not typically involve the appearance of bowel on the skin.
C. Infection could cause wound complications but would not lead to the sudden appearance of bowel outside the body.
D. Dehiscence is the partial or complete separation of wound edges, but it does not involve the protrusion of internal organs. Evisceration is a more severe progression where internal organs are exposed.

A. Palpates brachial artery before inflating the blood pressure cuff. B. Counts the client's respirations while palpating the radial pulse. C. Asks the client to relax the arm before taking the blood pressure. D. Inserts the thermometer into the sublingual pocket after the client sips water.

Correct Answer is D

Explanation

A. Palpating the brachial artery before inflating the blood pressure cuff is a correct technique to locate the artery and ensure accurate blood pressure measurement.
B. Counting respirations while palpating the radial pulse is a correct technique as it minimizes the risk of the client altering their breathing pattern.
C. Asking the client to relax their arm before taking the blood pressure is an appropriate step to ensure an accurate measurement.
D. Inserting a thermometer into the sublingual pocket after the client sips water can affect the accuracy of the temperature reading, as water can alter the temperature measurement.

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The practical nurse (PN) is documenting the insertion of a urinary catheter for a female client with urinary retention. What information should the PN include during the electronic documentation of the procedure? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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