A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

Position the client supine.

Cleanse the perineal area with an antiseptic.

Deflate the balloon halfway and then pull out the catheter.

Have the client bear down during removal.

Answer and Explanation

The Correct Answer is C

Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.

Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.

Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.

Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.

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Correct Answer is D

Explanation

Choice A reason: Flank pain is not a sign of an allergic transfusion reaction. Flank pain is a pain in the side of the abdomen or back, usually caused by kidney problems, such as infection, stones, or injury. Flank pain can be a sign of a hemolytic transfusion reaction, which is a serious complication that occurs when the donor blood is incompatible with the recipient's blood type.

Choice B reason: Elevated blood pressure is not a sign of an allergic transfusion reaction. Elevated blood pressure is a condition where the force of the blood against the artery walls is too high, which can increase the risk of heart disease, stroke, and kidney damage. Elevated blood pressure can be a sign of a hypertensive transfusion reaction, which is a rare complication that occurs when the donor blood has a higher sodium level than the recipient's blood.

Choice C reason: Distended neck veins are not a sign of an allergic transfusion reaction. Distended neck veins are a sign of increased pressure in the right side of the heart or the superior vena cava, which can be caused by heart failure, pulmonary hypertension, or obstruction. Distended neck veins can be a sign of a circulatory overload transfusion reaction, which is a complication that occurs when the blood volume or rate of infusion is too high for the recipient's cardiovascular system.

Choice D reason: Wheezing is a sign of an allergic transfusion reaction. Wheezing is a high-pitched whistling sound that occurs when the airways are narrowed or inflamed, which can cause difficulty breathing, coughing, or chest tightness. Wheezing can be a sign of an allergic transfusion reaction, which is a hypersensitivity response to the donor blood or its components, such as plasma proteins, antibodies, or preservatives. An allergic transfusion reaction can range from mild to severe, and can be treated with antihistamines, corticosteroids, or epinephrine.

A. Confirm the client's identity by checking their wristband. B. Provide for the client's privacy by closing the curtains. C. Assist the client into the Sims' position. D. Insert the tip of the enema tubing into the client's rectum.

Correct Answer is A,B,C,D

Explanation

Choice A reason: Confirming the client's identity by checking their wristband is the first step to ensure that the right client receives the right treatment.

Choice B reason: Providing for the client's privacy by closing the curtains is the second step to respect the client's dignity and comfort.

Choice C reason: Assisting the client into the Sims' position is the third step to facilitate the insertion of the enema tubing and the flow of the solution. The Sims' position is a side-lying position with the upper leg flexed and the lower leg straight.

Choice D reason: Inserting the tip of the enema tubing into the client's rectum is the fourth and final step to administer the enema. The nurse should lubricate the tip of the tubing, gently insert it about 3 to 4 inches into the rectum, and release the clamp to allow the solution to flow. The nurse should monitor the client for any signs of discomfort or cramping and adjust the flow rate accordingly.

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A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

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