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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Changing dressings is important but not the priority over assessing cardiac status in an electrical shock injury.
B. Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be immediate and life-threatening consequences of electrical shock injuries.
C. Administering pain medication can be done once the client's cardiac status has been evaluated and stabilized.
D. While maintaining adequate urine output is important, assessing cardiac status takes precedence.

A. "The elastic bandage will prevent a postoperative wound infection." B. "The elastic bandage will prevent excessive edema." C. "The elastic bandage will keep you from seeing the surgical site." D. "The elastic bandage will keep the sutures from loosening."

Correct Answer is B

Explanation

A. While wound infection prevention is important, the elastic bandage primarily addresses edema control.
B. Maintaining an elastic bandage around the residual limb helps to compress soft tissues and minimize edema, promoting healing and aiding in the shaping of the residual limb for future prosthesis fitting.
C. The purpose of the elastic bandage is not related to preventing the client from seeing the surgical site.
D. The elastic bandage is not primarily used to secure sutures; its main purpose is edema control.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse?

Correct Answer is B

Explanation

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