When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?
When the client voided following catheter removal.
Color of the urine during the catheter removal.
Time of the last dose of IV antibiotic administration.
Intake and output reports for the previous shift.
The Correct Answer is A
A. When the client voided following catheter removal:
This information is crucial because it indicates the return of the client's ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.
B. Color of the urine during catheter removal:
While the color of the urine during catheter removal may provide some insight into the client's urinary condition, it is not as critical as knowing when the client voided after catheter removal to assess urinary function.
C. Time of the last dose of IV antibiotic administration:
While the timing of the last dose of IV antibiotic administration is important for managing the client's urinary tract infection, it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.
D. Intake and output reports for the previous shift:
Intake and output reports are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Risk for infection:
Neuropathy can compromise the ability to detect injuries or wounds on the feet. Consequently, there's a risk of wounds going unnoticed, becoming infected, and leading to serious complications. While preventing infection is important, the primary concern in this scenario is preventing the occurrence of wounds or skin breakdown in the first place.
B. Impaired physical mobility:
Impaired physical mobility may be a concern for clients with neuropathy, especially if it affects their ability to walk or perform activities of daily living. However, in this scenario, the client is reporting increasing numbness and tingling in the lower extremities, indicating a sensory issue rather than a motor one. Therefore, while physical mobility is important, it may not be the immediate priority for promoting foot care in this case.
C. Risk for impaired skin integrity:
This option addresses the potential risk of skin breakdown or damage due to decreased sensation in the lower extremities, which is characteristic of neuropathy. With increasing numbness and tingling, there's a higher risk that the client may not be able to perceive injuries or pressure points, leading to skin damage or ulceration. Preventing skin integrity issues is crucial to avoid complications such as infections or wounds.
D. Self-care deficit:
Neuropathy can indeed impact a person's ability to perform self-care activities, including foot care. However, the priority in this scenario is to prevent complications related to neuropathy, such as skin integrity issues, rather than addressing deficits in self-care abilities. While self-care education and support may be necessary in the long term, immediate intervention to prevent skin breakdown takes precedence.
Correct Answer is D
Explanation
A. Criminal assault and battery:
Criminal assault and battery involve intentionally causing harm to another person without their consent. In this scenario, the nurse's actions were aimed at providing aid and ensuring the victim's safety. There is no indication of any intentional harm or violence toward the victim.
B. Negligent acts of omission:
Negligent acts of omission occur when a healthcare provider fails to act in a manner consistent with the standard of care, resulting in harm to another person. In this scenario, the nurse took certain actions to assist the victim, such as turning off the engine key and assessing the victim's condition. There is no indication of negligent omission as the nurse took appropriate actions given the circumstances.
C. Abandonment of the victim:
This applies if a healthcare professional leaves a patient in need of care without ensuring appropriate transfer of care. In this scenario, the nurse handed over the situation to EMS before leaving.
D. Good Samaritan immunity:
Good Samaritan laws protect individuals, including nurses, who voluntarily provide assistance in emergency situations from legal liability, as long as their actions are within the scope of their knowledge and training and are performed in good faith. The nurse stopped to help, provided care, and then reported to EMS personnel before leaving, which is consistent with the protection offered by Good Samaritan laws.
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