A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply).

Measurement of residual urine after urination

An open perineal wound

Relief of urinary retention

Convenience for the nursing staff or the client's family

routine acquisition of a urine specimen

Answer and Explanation

Correct Answer : A,B,C

A.   Measurement of residual urine after urination is an indication of urinary catheterization because it can help diagnose conditions such as neurogenic bladder, bladder outlet obstruction, or urinary retention.
B.   An open perineal wound is an indication for urinary catheterization because it can prevent contamination of the wound by urine and facilitate wound healing.
C.   Relief of urinary retention is an indication of urinary catheterization because it can prevent complications such as bladder distension, infection, or renal damage.
D.   Convenience for the nursing staff or the client's family is not an indication of urinary catheterization because it can increase the risk of catheter-associated urinary tract infection (CAUTI), trauma, or encrustation.
E.   routine acquisition of a urine specimen is not an indication for urinary catheterization because it can be obtained by other methods such as clean catch, midstream, or suprapubic aspiration.

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Correct Answer is C

Explanation

A. Observing the client's respiratory status is also important, but it is an ongoing assessment rather than an immediate action.

B. Monitoring intake and output every 8 hours is important for overall fluid balance, but it is not the top priority in this situation.

C. This is crucial to prevent aspiration, which can occur if the feeding formula enters the lungs, leading to pneumonia or other serious complications. Elevating the head of the bed helps keep the esophagus above the stomach, reducing the risk of aspiration.

D. Checking residual volume every 4 to 6 hours is a part of enteral feeding care, but it is not the top priority. Monitoring respiratory status takes precedence due to the potential risk of aspiration.

A. Request a prescription for an indwelling urinary catheter. B. Take the client to the bathroom every 2 hr. C. Remind the client to tell the nurse when he has to urinate. D. Use adult diapers to prevent frequent clothing changes.

Correct Answer is B

Explanation

A. Requesting a prescription for an indwelling urinary catheter should be considered a last resort. Catheters come with risks of infection and other complications, so they should only be used when other interventions have failed.
B. Taking the client to the bathroom every 2 hours is a proactive approach to managing urinary incontinence in older adults with dementia. This helps ensure that the client has regular opportunities to empty their bladder, reducing the likelihood of accidents.
C. Reminding the client to tell the nurse when he has to urinate may not be effective in clients with dementia, as they may have difficulty recognizing or communicating their need to urinate.
D. Using adult diapers should also be considered a last resort and should not be the primary intervention. While they can provide a temporary solution, they do not address the underlying issue and can contribute to skin problems if not changed frequently.

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A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply).

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Explanation

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