While inserting an indwelling urinary catheter into a female client, the nurse observes urine flow in the tubing. Which action should be taken next?

Document the color and clarity of the urine.

Inflate the balloon with 5 mL of sterile water.

Ask the client to breathe deeply and slowly exhale.

Insert the catheter an additional inch.

Answer and Explanation

The Correct Answer is B

A.   While documenting the color and clarity of the urine is important for assessing the client's urinary output and potential issues, it is not the immediate next step in the catheter insertion process. This step typically comes after the catheter is fully inserted and secured.
B.   Once urine flow is observed, the next step is to inflate the balloon of the indwelling catheter to secure it in place within the bladder. This ensures the catheter remains correctly positioned and does not move out of the bladder, which is crucial for effective drainage and preventing accidental dislodgement.
C.   Asking the client to breathe deeply and exhale does not impact the catheterization process and is not related to the next immediate step after observing urine flow. This action might be helpful in other contexts, such as reducing anxiety or discomfort, but it does not address the technical steps required for catheter insertion.
D.   If urine flow is observed in the catheter, it indicates that the catheter is already in the bladder. Inserting the catheter an additional inch is unnecessary and could potentially cause trauma or discomfort. Proper catheter placement is confirmed by the observation of urine flow, and additional insertion is not required.

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Correct Answer is B

Explanation

A. This option does not correspond to one of Erik Erikson's stages. Erikson's theory includes eight stages of psychosocial development, and this specific stage is not part of his framework. While depression is a relevant concern in older adults, the correct terminology and stage must be identified based on Erikson’s theory.
B. This is Erikson's eighth and final stage of psychosocial development, typically occurring in late adulthood. In this stage, individuals reflect on their lives and either achieve a sense of integrity and fulfillment or experience despair and regret. The behaviors of withdrawing from friends, crying often, and seeking increased contact with family members are consistent with feelings of despair, as individuals may struggle with reflecting on their lives and their sense of accomplishment.
C. This is Erikson's sixth stage, which occurs during young adulthood (approximately ages 18 to 40). In this stage, individuals focus on forming intimate relationships and avoiding isolation. The behaviors described are more characteristic of older adulthood rather than young adulthood, so this stage is not applicable to the client's situation.
D. This is Erikson's first stage, occurring in infancy (from birth to about 18 months). During this stage, the primary task is developing trust in caregivers and the environment. The client’s behaviors are not related to the issues of trust or mistrust from early childhood but rather reflect challenges faced in older adulthood.

A. Determine which member of the nursing staff brought the cup of coffee to the client. B. Consult with the dietician to learn if the client is allowed to drink coffee. C. Remove the coffee from the tray, advising the client that it is not included in the diet. D. Remind the client that no milk or creamer can be added to the coffee.

Correct Answer is C

Explanation

A. While it’s important to understand how the coffee ended up on the tray, determining which staff member made the mistake does not address the immediate issue of ensuring the client’s diet is appropriate. The priority should be to correct the dietary error and ensure that the client receives only what is appropriate for their diet.
B. Consulting with a dietician could provide clarity on dietary restrictions and allowances. However, if the client is on a clear liquid diet, coffee is typically not included because it may have additives (like milk or creamer) or may not be considered suitable for the clear liquid diet.
C. Coffee, unless specified as permissible, generally does not meet the criteria for a clear liquid diet due to its potential to be mixed with non-clear substances and its stimulant properties. Removing the coffee and informing the client of the dietary restriction ensures that the client adheres to the prescribed diet and avoids potential complications or issues with their treatment.
D. This action is not suitable for a clear liquid diet. Coffee itself is typically not allowed on a clear liquid diet, regardless of whether milk or creamer is added. This choice does not address the fundamental issue of the coffee being inappropriate for the client’s diet.

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While inserting an indwelling urinary catheter into a female client, the nurse observes urine flow in the tubing. Which action should be taken next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is C

Explanation

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