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 B

Explanation

A - Using a stiff toothbrush is not appropriate for oral care in immobile clients, as it can irritate or damage the gums and oral tissues. A soft-bristled toothbrush is recommended to ensure gentle cleaning.

B - Turning the client on his side is the correct action to prevent aspiration. This position allows fluids and saliva to drain from the mouth, reducing the risk of aspiration, which is critical for immobile clients.

C - Using the thumb and index finger to keep the client’s mouth open can lead to accidental injury. Instead, a padded tongue blade should be used to maintain the client’s mouth open safely during oral care.

D - Applying petroleum jelly to the lips should be avoided, as it is oil-based and can increase the risk of aspiration if inhaled. A water-based lubricant or lip balm should be used instead.

A. Elevate the bed to a position of comfort for the nurse. B. Acquire the help of several people to lift the client. C. Place the wheelchair at a 90° angle to the bed. D. Lock the wheels of the bed and the wheelchair.

Correct Answer is D

Explanation

A. Elevating the bed for the comfort of the nurse does not address the safety and comfort of the client during the transfer.
B. While it's important to have assistance if needed, using several people to lift the client may not always be necessary or appropriate.
C. This positioningis not optimal, as it makes it harder for the client to pivot and sit on the wheelchair.
D. Ensuring the wheels of both the bed and the wheelchair are locked helps maintain stability and safety during the transfer process, reducing the risk of accidental movement and potential falls.

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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).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

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A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?