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 B
Explanation
Choice A Reason:
Telling the client to discuss the decision with her family implies that the family should influence or make the decision for the client. The decision to continue or discontinue treatment is a personal one that the client should make based on their own values and preferences.
Choice B Reason:
Supporting the client's decision to stop the treatment is correct. When a client with end-stage kidney disease decides to stop dialysis treatment, it's essential for the nurse to respect the client's autonomy and support their decision. The client has the right to make decisions about their own healthcare, including the decision to discontinue a treatment that is no longer aligned with their goals and wishes.
Choice C Reason:
Discussing alternative treatment methods may be appropriate in some cases, but if the client has made an informed decision to stop dialysis, the focus should be on respecting and supporting that decision rather than presenting alternatives.
Choice D Reason:
Involving the facility chaplain may be beneficial if the client desires spiritual or emotional support during this difficult decision-making process, but it should be at the client's request, not imposed by the nurse.
Correct Answer is B
Explanation
b. This must be very frightening for you. Let's talk more about it.
It is important for the nurse to acknowledge the client's fears and show empathy towards them. By saying "This must be very frightening for you," the nurse validates the client's feelings and shows that they are being heard.
Additionally, by suggesting that they talk more about it, the nurse can work towards building a therapeutic relationship with the client and gain more insight into their thought processes.
The other options are not appropriate because:
a. The nurse should not deny the client's beliefs or try to convince them that they are wrong. This can cause
the client to feel invalidated and may make them less likely to trust the nurse.
c. While it is important to understand the client's perspective, this question may come off as confrontational and accusatory.
d. Similarly, this question may be perceived as confrontational and may make the client defensive. It is important to approach the client with empathy and understanding rather than skepticism.
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