A client in the recovery room following a procedure is unable to void, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?
Remove the catheter and palpate the client's bladder for residual distention.
Remove the catheter and replace with an indwelling catheter.
Allow the bladder to empty completely or up to 1,000 mL of urine.
Clamp the catheter for thirty minutes and then resume draining.
The Correct Answer is C
Choice A: Remove the catheter and palpate the client's bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.
Choice B: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.
Choice C: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.
Choice D: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31.6"]
Explanation
The correct answer is : 31.6 mL
Let’s calculate this step by step:
Step 1: Convert 10 mg of teriparatide to mcg. We know that 1 mg = 1000 mcg. So, 10 mg = 10 × 1000 mcg = 10000 mcg.
Step 2: The medication is labeled as 760 mcg/2.4 ml. This means that 760 mcg of the medication is present in 2.4 mL.
Step 3: Now, we need to find out how many ml will contain 10000 mcg of the medication. We can set up a proportion to solve this:
(760 mcg / 2.4 ml) = (10000 mcg / x mL)
Step 4: Solving for x, we cross-multiply and divide:
x ml = (10000 mcg × 2.4 ml) ÷ 760 mcg
Step 5: Calculate the result:
x ml = 24000 mcg·ml ÷ 760 mcg = 31.57894736842105 mL
Step 6: If rounding is required, round to the nearest tenth:
x ml = 31.6 mL
So, the nurse should administer 31.6 mLof the medication.
Correct Answer is ["B","C","D","F"]
Explanation
Choice A reason: Alcohol consumption will not produce vascular changes is incorrect information. Alcohol consumption can increase blood pressure by causing vasoconstriction, fluid retention, and interference with antihypertensive medications. The nurse should advise the client to limit alcohol intake to no more than one drink per day for women and two drinks per day for men.
Choice B reason: Sodium intake can be regulated by limiting canned foods in the diet is correct information. Sodium intake can increase blood pressure by causing fluid retention and increasing vascular resistance. The nurse should advise the client to limit sodium intake to no more than 2300 mg per day and avoid processed foods that are high in sodium, such as canned foods, soups, sauces, and snacks.
Choice C reason: Salt substitutes can help with maintaining a healthy diet is correct information. Salt substitutes can reduce sodium intake by replacing sodium chloride with potassium chloride or other minerals. The nurse should advise the client to use salt substitutes sparingly and consult with their healthcare provider before using them if they have kidney disease or take certain medications that affect potassium levels.
Choice D reason: Weight management is promoted by taking daily walks for thirty minutes is correct information. Weight management can lower blood pressure by reducing body fat, improving blood circulation, and enhancing insulin sensitivity. The nurse should advise the client to maintain a healthy weight and engage in moderate physical activity for at least 150 minutes per week.
Choice E reason: Blood pressure readings should be taken at noontime is incorrect information. Blood pressure readings should be taken at different times of the day, preferably in the morning and evening, to monitor fluctuations and trends. The nurse should advise the client to use a home blood pressure monitor that is accurate and calibrated and follow proper techniques for measuring blood pressure.
Choice F reason: Uncontrolled hypertension can lead to renal damage is correct information. Uncontrolled hypertension can damage the blood vessels in the kidneys, leading to reduced kidney function and chronic kidney disease. The nurse should advise the client to follow their prescribed treatment plan and monitor their blood pressure regularly.
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