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 A
Explanation
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.
Correct Answer is ["B","C","D","E"]
Explanation
A. Encourage increased fluid intake and measure urinary output every 8 hours:
While hydration and monitoring urinary output are important aspects of overall health care, they are not specifically related to managing chronic pain. Therefore, this intervention may not be directly relevant to addressing the client's pain.
B. Assist the client to ambulate as much as possible during waking hours:
Ambulation helps maintain mobility, prevent complications like muscle atrophy and deep vein thrombosis, and can improve overall well-being. For clients with chronic pain, assisting with ambulation can be beneficial in managing pain and improving quality of life. The goal is to balance activity with the client's pain tolerance and capabilities.
C. Determine client's subjective measure of pain using a numerical pain scale:
Using a numerical pain scale helps assess the intensity of pain and monitor changes over time. It provides valuable information for tailoring pain management strategies to the client's needs and allows for evaluating the effectiveness of interventions.
D. Provide comfort measures such as topical warm application and tactile massage:
Comfort measures such as warm applications and massage can help alleviate pain and promote relaxation. These interventions address the client's comfort and well-being, making them appropriate for inclusion in the plan of care for managing chronic pain.
E. Implement a 24-hour schedule of routine administration of prescribed analgesic:
Establishing a regular schedule of analgesic administration helps maintain consistent pain control and prevents breakthrough pain. This intervention is essential for managing chronic pain effectively and promoting the client's comfort and quality of life.
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