A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
Skin breakdown
Infection
Neurogenic bladder
Phlebitis
The Correct Answer is B
A) Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary risk associated with the observations noted.
B) A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection. Additionally, if the urinary catheter bag is not positioned below the level of the bladder, urine can reflux back into the bladder, which also increases the risk of infection.
C) Neurogenic bladder is a condition typically associated with nerve damage, not directly related to the position of the catheter bag or kinked tubing.
D) Phlebitis is inflammation of a vein, which would not be directly caused by the issues noted with the urinary catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Generalized abdominal pain reported by a client with peritonitis indicates visceral pain.
B) Pain in the left shoulder reported by a client with pancreatitis is an example of referred pain, as it occurs at a site distant from the actual pathology.
C) Substernal chest pain reported by a client with angina indicates cardiac pain, not referred pain.
D) Incisional pain reported by a postoperative client is localized and does not indicate referred pain.
Correct Answer is D
Explanation
A. While pain assessment is important, ensuring airway patency takes priority over pain assessment in a client who has received sedation.
B. Monitoring temperature is important but is not the priority in this scenario.
C. Warmth of extremities is not as critical as assessing the airway.
D. Gag reflex assessment is essential to evaluate the client's ability to protect their airway and prevent aspiration, especially after receiving sedation.
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