A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?
"You cannot drink fluids for 4 hours after the procedure."
"You will need to urinate before the procedure."
"You will feel pressure when I inflate the catheter balloon."
"You will have a leg bag to collect the urine."
The Correct Answer is B
The correct answer is B. "You will need to urinate before the procedure." The rationale for this information is that intermittent catheterization is a method of draining urine from the bladder using a thin, flexible tube called a catheter. It is used to measure residual urine, which is the amount of urine left in the bladder after voiding. Residual urine can indicate problems with bladder function, such as obstruction, infection, or nerve damage .
To measure residual urine, the client should first empty their bladder by urinating normally. Then, the nurse will insert the catheter into the urethra and advance it into the bladder.The nurse will measure the amount of urine that drains out of the catheter and record it as residual urine. The nurse will then remove the catheter and dispose of it .
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. "Fidelity involves keeping promises made to clients." The rationale for this statement is that fidelity is a principle of ethics that requires nurses to be faithful, loyal, and trustworthy to their clients. Fidelity means that nurses should honor their commitments and obligations to their clients, such as following through with care plans, respecting confidentiality, and being honest. Fidelity also implies that nurses should advocate for their client's best interests and protect them from harm.
Correct Answer is D
Explanation
Choice A reason:
Infiltration is not correct: Infiltration occurs when the infused fluid or medication leaks into the surrounding tissue instead of flowing into the vein. This can lead to swelling, coolness, and pallor around the insertion site.
Choice B reason:
Extravasation is not correct: Extravasation is similar to infiltration but specifically refers to the infiltration of vesicant medications, which can cause tissue damage and necrosis.
Choice C reason:
Circulatory overload is not correct: Circulatory overload occurs when a large volume of fluid is infused too quickly, overloading the circulatory system and potentially leading to fluid overload, pulmonary edema, and other related symptoms.
Choice D reason:
Phlebitis is the appropriate fingings. The nurse should document the finding of redness and warmth around the peripheral catheter insertion site as phlebitis. Phlebitis is the inflammation of a vein, often caused by mechanical irritation, chemical irritation, or infection. In this case, the redness and warmth at the insertion site are indicative of inflammation, which is a common sign of phlebitis.
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