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 A

Explanation

A. Having the client wear a mask is the most appropriate precaution for safely
transporting a client with active pulmonary tuberculosis (TB) who requires airborne precautions. This helps contain potentially infectious respiratory droplets.
B. Asking the x-ray technician to come to the client's room to obtain a portable X-ray is a reasonable option, but it may not always be feasible depending on the facility's resources and policies.
C. Notifying the x-ray department that the client requires airborne precautions is an important step, but it is not sufficient on its own. The client should also wear a mask during transport.
D. Wearing a filtration mask and gloves during transport is not enough. The nurse should also ensure that the client is wearing a mask to contain respiratory secretions.

A. Use a stiff toothbrush to clean the client's teeth. B. Turn the client on his side before starting oral care. C. Use the thumb and index finger to keep the client's mouth open. D. Apply petroleum jelly to the client's lips after oral care.

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.

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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 caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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