A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?

Use sterile water to inflate the balloon.

Instruct the client to clean from front to back with an antiseptic solution.

Collect urine from the catheter's port.

Use a sterile specimen container.

Answer and Explanation

The Correct Answer is D

When collecting a urine specimen via straight catheterization, it is important to use a sterile specimen container to maintain the integrity of the sample and prevent contamination. Using a non-sterile container can introduce bacteria and affect the accuracy of the culture and sensitivity results.

The other options mentioned are incorrect:

Using sterile water to inflate the balloon: This action is relevant when inflating the balloon of an indwelling urinary catheter, but in a straight catheterization, there is no balloon involved.

Instructing the client to clean from front to back with an antiseptic solution: This instruction is appropriate for cleaning the urethral meatus before inserting an indwelling urinary catheter, but in a straight catheterization, the nurse performs the procedure using sterile technique and does not require the client to clean themselves.

Collecting urine from the catheter's port: In a straight catheterization, the nurse collects urine directly from the catheter tube using a sterile syringe or collection container, rather than from a separate port.

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Correct Answer is B

Explanation

After administering lactulose to a client with cirrhosis, the nurse should monitor for the adverse effects of diarrhea. Lactulose is a laxative commonly used in the treatment of hepatic encephalopathy, which can occur in individuals with cirrhosis. One of the intended effects of lactulose is to promote bowel movements and reduce the absorption of ammonia in the gut, thus helping to manage hepatic encephalopathy.

While lactulose can cause adverse effects such as diarrhea, it is not typically associated with peripheral edema. Peripheral edema is often seen in cirrhosis due to fluid retention caused by liver dysfunction.

Dry mouth and headache are less commonly associated with lactulose use and are not typically the primary adverse effects to monitor for in this scenario.

A. Lower the height of the solution container. B. Stop the enema and document that the client did not tolerate the procedure. C. Encourage the client to bear down D. Allow the client to expel some fluid before continuing

Correct Answer is D

Explanation

When the client experiences cramping during the enema administration, it indicates that the colon is becoming distended. By allowing the client to expel some of the fluid, the pressure in the colon is reduced, which can help alleviate the discomfort and cramping. The nurse should pause the administration of the enema and allow the client to release some fluid before continuing.

The other options mentioned are not appropriate or effective actions to relieve the client's discomfort:

Lowering the height of the solution container: Lowering the height of the solution container will decrease the force of the fluid flow but may not address the underlying cause of the cramping. Allowing the client to expel some fluid is a more appropriate intervention.

Stopping the enema and documenting that the client did not tolerate the procedure: While it is important to monitor the client's tolerance during the procedure, abruptly stopping the enema and documenting intolerance may not be necessary if the discomfort can be relieved by allowing the client to expel some fluid. The nurse should prioritize relieving the discomfort before deciding to stop the procedure.

Encouraging the client to bear down: Bearing down or pushing can increase intra-abdominal pressure and exacerbate the cramping. This action is not recommended in this situation.

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A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cirrhosis and a prescription for lactulose. Following administration, the nurse should monitor the client for which of the following adverse effects?

Correct Answer is B

Explanation

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Correct Answer is D

Explanation

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