A nurse is caring for a client who had a transurethral resection of the prostate and now is receiving continuous bladder irrigation. Which of the following actions should the nurse take? (Select all that apply.)
Document urine color
Monitor the client for reports of bladder spasms.
Check the drainage tubing for obstructions
Maintain the client in a left side-lying position
Use clean technique for intermitent irrigation
Correct Answer : A,B,C
The correct answers are a. Document urine color, b. Monitor the client for reports of bladder spasms, and
c. Check the drainage tubing for obstructions.
a. Documenting urine color is important to monitor for any changes that may indicate complications or issues with the bladder irrigation. It helps identify any bleeding or clot formation.
b. Monitoring the client for reports of bladder spasms is crucial as bladder spasms can indicate irritation or obstruction in the urinary system. Prompt intervention can be provided to alleviate discomfort and prevent complications.
c. Checking the drainage tubing for obstructions is essential to ensure proper flow of the bladder irrigation solution. Obstructions in the tubing can lead to inadequate irrigation, which can affect the effectiveness of the procedure and potentially lead to complications.
d. Maintaining the client in a left side-lying position is not specifically indicated for continuous bladder irrigation after a transurethral resection of the prostate. The client's position should be based on their comfort and overall condition, and there is no specific requirement for a left side-lying position in this context.
e. Using clean technique for intermitent irrigation is not appropriate for continuous bladder irrigation. Continuous bladder irrigation requires aseptic technique to reduce the risk of infection and contamination.
By performing these actions, the nurse ensures proper monitoring, documentation, and maintenance of the bladder irrigation system, promoting the client's safety and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A newly licensed nurse who is having difficulty finishing client care tasks during their shift should try to complete one task before moving on to the next. This can help the nurse stay focused and organized, and prevent them from becoming overwhelmed.
The other options are not recommended for time management.
a) Delegating complicated tasks to an RNmay not be appropriate or allowed, depending on the task and the nurse's scope of practice.
b) Documenting all client care at the end of the shiftcan lead to errors and omissions.
c) Performing quick tasks before time-consuming tasks may not be the most efficient use of time, as it can lead to unfinished tasks at the end of the shift.
Correct Answer is D
Explanation
When a mother states that she should have her baby latch on to both the nipple and areola during breastfeeding, it demonstrates an understanding of the correct latch technique. A proper latch involves the baby taking in not just the nipple but also a portion of the surrounding areola. This ensures effective milk transfer and helps prevent nipple soreness or damage.
"My baby should breastfeed 5 to 10 minutes on each breast": This statement is not entirely accurate. It is important to understand that breastfeeding duration can vary among infants, and there is no fixed timeframe for how long a baby should breastfeed on each breast. Some infants
may nurse for shorter periods, while others may take longer. The focus should be on ensuring that the baby is effectively nursing and getting enough milk rather than adhering strictly to a specific time limit.
"I should keep my baby on a strict feeding schedule": This statement is incorrect. Breastfeeding on demand, also known as responsive feeding, is generally recommended for newborns.
Newborns should be fed whenever they show signs of hunger, such as rooting, sucking motions, or increased alertness. Strict feeding schedules can interfere with the baby's natural feeding cues and hinder milk supply establishment.
"I should not wake my baby during the night to breastfeed": This statement is not accurate, especially for a 5-day-old newborn. Newborns typically need frequent feeding, including during the night, to meet their nutritional needs and support proper growth and development. It is generally recommended to wake a sleeping newborn every 2-3 hours during the night to ensure adequate feeding and prevent excessive weight loss.
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