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 ["B","C","D","E"]
Explanation
Choice A reason: This is incorrect because instructing the client and family to reconsider end of life choices is disrespectful and insensitive. The nurse should respect the client's autonomy and preferences and support their decisions.
Choice B reason: This is correct because teaching the client how to use guided imagery is a helpful intervention for coping with feelings related to death and dying. Guided imagery is a relaxation technique that involves visualizing positive images and scenarios that can reduce stress, anxiety, and pain.
Choice C reason: This is correct because recording the client's desire to live is an important intervention for coping with feelings related to death and dying. The nurse should acknowledge and validate the client's emotions and help them express their hopes and fears.
Choice D reason: This is correct because encouraging family to visit frequently is a beneficial intervention for coping with feelings related to death and dying. The nurse should facilitate family involvement and communication and help the client maintain meaningful relationships.
Choice E reason: This is correct because encouraging family to bring the client old photographs is a useful intervention for coping with feelings related to death and dying. The nurse should assist the client in reminiscing and reviewing their life story and achievements.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because seizure precautions are not indicated for dopamine administration. Dopamine does not lower the seizure threshold or cause convulsions.
Choice B reason: This is incorrect because monitoring serum potassium frequently is not necessary for dopamine administration. Dopamine does not affect potassium levels or cause hyperkalemia or hypokalemia.
Choice C reason: This is correct because ensuring pump accuracy to prevent toxicity is essential for dopamine administration. Dopamine is a potent vasoconstrictor that can cause tissue necrosis, gangrene, and hypertension if overdosed.
Choice D reason: Dopamine is given to hypotensive patients, meaning they may be weak, dizzy, or at risk of falls.Ambulating frequently could worsen hypotension and increase fall risk rather than help the patient. Instead, the nurse should monitor the patient’s hemodynamic status and ensure bed rest as needed until blood pressure stabilizes.
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