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."

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason:

Pain with movement of the left great toe is incorrect finding: Pain may be expected in a client with a fractured left tibia, especially if the great toe is moved. Pain is more related to the fracture and may not specifically indicate altered tissue perfusion.

Choice B reason:

Faint pedal pulse of the left leg is correct because it indicates that the blood flow to the foot is diminished. The pedal pulse is the pulse felt on the top of the foot, and its faintness could suggest reduced arterial blood flow to the foot.

Choice C reason:

Warm skin temperature distal to the pin site is incorrect: Warm skin distal to the pin site may indicate adequate blood flow and could be a normal finding. Warmth is generally associated with increased blood flow to the area.

Choice D reason:

Purulent drainage at the pin site is incorrect. Purulent drainage at the pin site could indicate an infection, but it is not directly related to altered tissue perfusion. Infection can lead to complications, but it does not necessarily indicate reduced blood flow to the extremity.

A. Instruct the client to lie supine with his knees flexed. B. Position the client in semi-Fowler's position. C. Cover the wound with a dry sterile dressing. D. Cover the wound with a transparent dressing.

Correct Answer is A

Explanation

The correct answer is choice A. Instruct the client to lie supine with his knees flexed. Choice A rationale: This position reduces tension on the abdominal incision and can help minimize further protrusion of the abdominal contents. It also facilitates easier coverage of the wound and can help prevent additional injury. Choice B rationale: Semi-Fowler's position is not appropriate in this scenario because it can increase intra-abdominal pressure and exacerbate the evisceration. It may also make it more difficult to manage the protruding organs and to cover the wound adequately. Choice C rationale: Covering the wound with a dry sterile dressing is not sufficient in the case of evisceration. The exposed organs need to be kept moist to prevent tissue drying and damage. Sterile saline-soaked dressings are typically recommended in such cases. Choice D rationale: A transparent dressing is not appropriate for evisceration as it does not provide the necessary moisture and protection. Transparent dressings are more suitable for minor wounds or as secondary dressings but not for exposed internal organs.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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