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 will have a leg bag to collect the urine."
"You will feel pressure when I inflate the catheter balloon."
"You cannot drink fluids for 4 hours after the procedure."
"You will need to urinate before the procedure."
The Correct Answer is D
Choice A Reason:
Choice B Reason:
Inflating a catheter balloon is typically not part of intermittent catheterization, as it is more commonly associated with indwelling catheters.
Choice C Reason:
There is no need for the client to restrict fluid intake before or after intermittent catheterization. In fact, adequate hydration is generally encouraged.
Choice D Reason:
Intermittent catheterization involves inserting a catheter into the bladder to empty it completely, typically to measure residual urine. Before performing intermittent catheterization, it's essential for the client to try to urinate naturally to ensure that the bladder is as empty as possible. This step helps to provide accurate measurements of residual urine and reduces the risk of complications. Therefore, the nurse should include this information in the teaching to ensure the client understands the procedure's proper preparation. While the use of a leg bag to collect urine may be part of the overall management plan, it is not specific to the teaching about preparing for intermittent catheterization.Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
The surgeon is incorrect. Surgeons primarily focus on the surgical procedure itself and the immediate postoperative care related to the surgery. They may not have a direct role in medication management or overall postoperative care beyond the surgical site.
Choice B Reason:
The pharmacist is incorrect. While pharmacists play a vital role in medication management, they typically focus on dispensing medications, providing drug information, and ensuring proper dosages and administration. They may not be directly involved in assessing fall rates or postoperative outcomes.
Choice C Reason:
The case manager is incorrect. Case managers are responsible for coordinating a patient's care and ensuring that it meets their overall healthcare needs. They may not have the expertise or authority to investigate and address specific safety concerns related to medication use and fall rates.
Choice D Reason:
The risk manager is correct. When a nurse identifies an issue related to patient safety, such as an increased fall rate associated with a specific medication like zolpidem, it is important to report these findings to the risk manager. The risk manager is responsible for assessing and addressing issues related to patient safety and quality improvement within the healthcare facility. They can investigate the matter further, collaborate with other members of the healthcare team, and implement necessary changes or protocols to mitigate the risk and improve patient safety. Reporting such findings to the risk manager is a crucial step in ensuring patient safety and quality of care.
Correct Answer is C
Explanation
Choice A Reason:
Documenting the event in the client's progress notes is not the immediate action to take. While it's important to document significant events, the priority is to stop the unauthorized disclosure of the client's information and address the privacy breach.
Choice B Reason:
Informing the client of the APs' actions is not the initial step to take. The priority is to address the issue and stop the conversation to prevent further disclosure of confidential information. However, the client may need to be informed about the breach of privacy as part of the organization's protocol.
Choice C Reason:
Telling the APs to stop the conversation is correct. Overhearing discussions about a client's personal information by unauthorized personnel is a breach of patient privacy and confidentiality, which is a serious violation of healthcare ethics and regulations. Therefore, the nurse should address the situation immediately by telling the assistive personnel (APs) to stop the conversation. Here's why each option is appropriate or not:
Choice D Reason:
Submitting an incident report to the risk manager is an appropriate step to take but should not be the first action. The immediate concern is to address the situation and stop the unauthorized discussion. After that, the incident should be documented and reported according to the facility's policies and procedures.
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