A nurse is preparing to administer medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh?

(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

The correct answer is choice A. Perform a bladder scan.

Choice A rationale:

Performing a bladder scan is the first action the nurse should take before proceeding with intermittent urinary catheterization. A bladder scan assesses the bladder's volume and determines if catheterization is necessary. It helps avoid unnecessary catheterizations, reduces the risk of infection, and promotes patient comfort.

Choice B rationale:

While cleansing the meatus and providing perineal care are important steps in preparing for urinary catheterization, they come after assessing the need for catheterization. Without knowing the bladder volume, these actions could be premature.

Choice C rationale:

Providing perineal care is important for maintaining hygiene and preventing infection, but it should be done after the decision for catheterization has been made based on the bladder scan results.

Choice D rationale:

Lubricating the catheter is a step that should be taken after the decision for catheterization is made and the need for catheterization is confirmed. It helps ease the insertion process and reduce discomfort for the patient.

The correct answer is choice B. Client states, "I started to itch after taking that medication."

Choice A rationale:

"Client is itching from medication." This statement is not a comprehensive description of the situation and lacks specific information. It doesn't provide any context about when the itching occurred or the client's own observation.

Choice B rationale:

"Client states, 'I started to itch after taking that medication.'" This choice is the correct answer because it accurately documents the client's own statement about the itching and the timing in relation to taking the medication. It includes a direct quote, which helps in maintaining accurate and patient-centered documentation.

Choice C rationale:

"It appears that the client has a rash from the medication." This statement includes an assumption and subjective language ("It appears"), which can be misleading in documentation. It's essential to provide factual and objective information in medical records.

Choice D rationale:

"Rash from medication noted." This choice lacks detail and doesn't capture the client's perspective or the timing of the symptom. It's important to include the client's statement and the time frame in which the symptom occurred.