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A nurse is planning care for a client who was admitted to the unit for pneumonia.

Exhibits

The nurse is planning care for the client.

Complete the following sentence by using the lists of options.

After providing perineal care and donning sterile gloves, the nurse should first

followed by
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

After providing perineal care and donning sterile gloves, the nurse should first lubricate the catheter tip followed by insert the catheter until urine flows.

Rationale:

  1. Lubricating the catheter tip ensures smooth insertion and minimizes discomfort or trauma to the urethra.
  2. Inserting the catheter until urine flows confirms proper placement before advancing slightly more to ensure complete drainage.


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Related Questions

Correct Answer is C

Explanation

A. Laboratory results Lab results are diagnostic data, not part of the health history. They are obtained separately through testing.
B. Physical examination findings The physical exam is a separate component of the assessment and is not included in the health history, which focuses on subjective data.
C. Health habits The health history includes subjective data provided by the client, such as dietary habits, exercise routine, smoking, alcohol use, sleep patterns, and medication use. This information helps the nurse understand the client’s lifestyle and risk factors.
D. Observed client behaviors While a nurse may take note of behaviors, the health history is based on the client’s self-reported information, not observations.

Correct Answer is ["A","B","C","D"]

Explanation

A. Stop the transfusion. The first action is to stop the transfusion to prevent further fluid overload.
B. Place the client in high-Fowler's position. This position reduces venous return to the heart and improves breathing and oxygenation.
C. Obtain a prescription for a diuretic. Diuretics (e.g., furosemide) help remove excess fluid, relieving pulmonary congestion and reducing strain on the heart.
D. Administer oxygen to the client. Oxygen helps relieve hypoxia caused by fluid buildup in the lungs.
E. Administer epinephrine to the client. Epinephrine is used for anaphylactic reactions, not circulatory overload. There is no indication of an allergic reaction in this scenario.

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