A nurse is caring for a postoperative client who has an indwelling urinary catheter. Which of the following actions should the nurse take when removing the catheter?
Rapidly deflate the balloon before removing the tubing.
Place the client in the dorsal recumbent position,
Reinsert the catheter if the client does not void within 1 hr.
Obtain a sterile urine specimen after catheter removal.
The Correct Answer is B
A) Rapidly deflate the balloon before removing the tubing:
Rapidly deflating the balloon is not recommended. The balloon should be deflated slowly to ensure complete deflation and prevent trauma to the urethra during removal.
B) Place the client in the dorsal recumbent position:
Placing the client in the dorsal recumbent position (lying on the back with knees bent and feet flat) is appropriate. This position allows for easier access to the catheter and ensures client comfort during the removal process.
C) Reinsert the catheter if the client does not void within 1 hr:
Reinserting the catheter after only 1 hour is premature. It is generally advised to monitor the client for up to 6-8 hours for spontaneous voiding before considering reinsertion. The client should be encouraged to drink fluids and attempts to void should be documented.
D) Obtain a sterile urine specimen after catheter removal:
Obtaining a sterile urine specimen immediately after catheter removal is not necessary. If a urine sample is required, it should be collected before the catheter is removed to ensure sterility
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) 2 tbsp peanut butter:
Peanut butter is relatively high in potassium, with approximately 200 mg per 2 tablespoons. This can contribute significantly to potassium intake and is not the best choice for someone needing to limit potassium.
B) 1 cup white rice:
White rice contains a relatively low amount of potassium compared to other foods, making it a suitable choice for someone with chronic kidney disease who needs to manage potassium levels. A cup of white rice has about 30 mg of potassium.
C) 1/2 cup nonfat yogurt:
Nonfat yogurt contains a moderate amount of potassium, approximately 350 mg per half-cup serving. This amount is significant and can contribute to elevated potassium levels if consumed frequently.
D) 1 medium baked potato with skin:
A medium baked potato with skin is very high in potassium, containing approximately 925 mg. This makes it unsuitable for clients who need to limit potassium intake, as it can easily exceed dietary limits.
Correct Answer is D
Explanation
A) Clear items from the client's surrounding area:
While it is important to clear items from the surrounding area to prevent injury during a seizure, this should be done after ensuring the client's immediate safety. Lowering the client to the floor takes precedence to prevent falls and potential injuries.
B) Loosen the client's restrictive clothing:
Loosening restrictive clothing can help ensure the client’s comfort and maintain airway patency during a seizure. However, this action is not the most immediate priority compared to lowering the client to the floor.
C) Obtain the client's vital signs:
Obtaining vital signs is important to assess the client's status, but it is not the immediate priority during the active phase of a seizure. Ensuring the client's safety by preventing falls and injuries comes first.
D) Lower the client to the floor:
Lowering the client to the floor is the most immediate priority during a seizure. This action helps to prevent the client from falling and sustaining injuries. Once the client is safely on the floor, other measures can be taken to protect them and monitor their condition.
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