A nurse is performing a bladder irrigation for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
Slowly instill 400 to 500 mL of the prescribed solution.
Clamp the drainage tubing distal to the injection port.
Use a syringe with a 19-gauge needle.
Withdraw the irrigation solution into the syringe.
The Correct Answer is A
Choice A rationale:
During bladder irrigation, the nurse should instill a specific volume of the prescribed irrigation solution into the bladder to facilitate the removal of clots, mucus, or other debris from the urinary catheter and bladder. The recommended volume to instill is usually 400 to 500 mL, which helps to effectively flush out the bladder without overdistending it.
Choice B rationale:
Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.
Choice C rationale:
Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.
Choice D rationale:
Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Justice refers to the fair distribution of resources and benefits. It pertains to treating individuals equitably and ensuring that their rights are respected. However, in this scenario, the nurse is specifically addressing the client's right to refuse treatment, which aligns more with the concept of autonomy.
Choice B rationale:
Veracity is the principle of truthfulness and honesty in communication between healthcare professionals and clients. While it is an important ethical principle, it does not directly relate to the client's right to refuse treatment. This right falls under the principle of autonomy, where individuals have the right to make decisions about their own healthcare, including the decision to refuse treatment.
Choice C rationale:
Fidelity, also known as loyalty or faithfulness, refers to the nurse's commitment to keeping promises and being dedicated to the well-being of the client. While respecting the client's autonomy is part of being faithful to their needs and preferences, the specific right to refuse treatment is better categorized under the principle of autonomy.
Choice D rationale:
Autonomy is the correct choice. Autonomy emphasizes an individual's right to make decisions regarding their own healthcare based on their values, beliefs, and preferences. In this context, the nurse's responsibility is to uphold the client's autonomy by respecting their decision to refuse treatment. The nurse should ensure that the client has been properly informed about the risks and benefits of the treatment and that their decision is voluntary and informed.
Correct Answer is C
Explanation
Choice A rationale:
The walking gait test is used to assess a client's walking pattern and balance, particularly for identifying abnormalities in gait. However, it doesn't specifically evaluate sensory functions, making it an inappropriate choice for this scenario.
Choice B rationale:
The plantar reflex test, also known as the Babinski reflex test, assesses the neurological integrity of the corticospinal tract. It involves stimulating the sole of the foot to elicit specific reflex movements. While this test is important in assessing neurological function, it doesn't directly evaluate sensory functions as requested in the question.
Choice C rationale:
The finger-to-nose test is a part of the neurological examination used to assess a client's coordination and proprioception. In this test, the client is asked to touch their nose with their index finger while alternating between eyes closed and eyes open. This evaluates their ability to sense the position of their limbs in space (proprioception) and their coordination. It directly addresses the focus of the question, making it the correct choice.
Choice D rationale:
The Romberg test evaluates a client's balance and proprioception. It involves having the client stand with their feet together and their eyes closed to assess their ability to maintain balance without visual input. While this test is relevant to sensory functions, it primarily assesses proprioception and balance rather than coordination, which the question is specifically targeting.
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