A client is voiding frequent small amounts 24-hours following the removal of an indwelling catheter, and a post-voided residual volume assessment is prescribed. Which explanation should the practical nurse (PN) provide to the client about why the procedure is necessary?
The catheterization is part of the prescribed bladder retraining program.
The catheterized volume determines the need to re-insert the indwelling catheter.
The catheterization will stimulate the bladder to empty more completely.
The catheterization procedure is an exercise in stimulus-response conditioning.
The Correct Answer is B
A. The post-voided residual volume assessment is not part of a bladder retraining program but is a diagnostic tool used to assess bladder function after catheter removal. This explanation misrepresents the purpose of the procedure.
B. The post-voided residual volume assessment measures how much urine remains in the bladder after the client has voided. This measurement helps determine if the bladder is emptying properly and whether there is a need for catheter re-insertion.
C. Post-voided residual volume assessment does not stimulate the bladder to empty more completely; instead, it measures the amount of urine left in the bladder. The procedure is diagnostic rather than therapeutic.
D. The post-voided residual volume assessment is a diagnostic procedure, not an exercise in conditioning. This explanation does not accurately describe the clinical purpose of the assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
The child’s symptoms—drowsiness, thick yellow secretions, low respiratory rate, and fever—along with the chest x-ray showing consolidation consistent with pneumonia, indicate that he is experiencing respiratory insufficiency. Respiratory insufficiency occurs when the respiratory system fails to meet the body's oxygen needs or remove carbon dioxide effectively.
Actions to Take:
1. Perform oropharyngeal suctioning
Suctioning is necessary to clear the thick yellow secretions that can obstruct the airway and contribute to respiratory insufficiency. It helps maintain a patent airway and improves the child's ability to breathe.
2. Provide humidified supplemental oxygen
Humidified oxygen helps to maintain airway moisture and improve oxygenation, which is critical for managing respiratory insufficiency. It can also help loosen secretions and alleviate symptoms related to pneumonia.
Parameters to Monitor:
1. Oxygen Saturation
Monitoring oxygen saturation is essential to assess the effectiveness of supplemental oxygen and interventions for respiratory insufficiency. Low oxygen saturation indicates that the respiratory system is not meeting the oxygen demands of the body.
2. Temperature
Temperature monitoring is important to assess the effectiveness of fever management and to monitor for potential worsening of the infection. Elevated temperature can exacerbate respiratory insufficiency and indicate ongoing infection.
Correct Answer is ["B","D","E"]
Explanation
A. Subdural hemorrhage
The head CT was negative for bleeding or edema, making a subdural hemorrhage unlikely.
B. Respiratory distress
Given the history of drowning and the current signs of respiratory acidosis (pH 7.31, PaCO2 51), the child is at high risk for respiratory complications, including distress.
C. Hyperthermia
Hyperthermia is not a typical immediate complication following drowning in cool water, and the current body temperature of the child is within the normal range.
D. Cerebral edema
Although the initial CT scan is negative for edema, secondary cerebral edema can develop hours after the incident, especially in cases of significant hypoxemia.
E. Acute asphyxia
The initial incident of drowning and the resultant hypoxemia (as indicated by abnormal blood gases) place the child at risk for complications related to acute asphyxia.
F. Hypertension
The child's blood pressure is currently within normal limits, and hypertension is not a common immediate complication following drowning.
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